I. Registration Personal Data * Note: you must submit a copy of the most updated CV for Hospital observer privilege application. E-mail your CV to: christine.drane@uhn.on.ca or fax to 416-603-6494 Please complete all the fields marked with * Title * First Name * Last Name Clinic/Department/Organization Country * Full Address City State/Province Postal/Zip Code Telephone Telefax * E-mail Scrub suit size Top Bottom Please check off the fields that apply to you : Anesthesiologist Neurologist Neurosurgeon Psychiatrist Psychologist PMR RN NP PA Others How did you hear about our workshop: Colleague Website E-Mail Others II. Registration Fee Package #1 (2 day visit) Canadian $ 375 Available Dates for 2011 March 7-8 November 21-22 Package #2 (4 day visit) Canadian $ 750 Available Dates for 2011 March 7-10 November 21-24

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