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REGISTRATION FOR PRIMARY CARE DIABETES BOOT CAMP

Date: Friday, March 2, 2012

Location: Burlington, Ontario

Registration: 8:30 am on March 2, 2012

Program time: 9:00 am to 1:00 pm

Registration deadline (space is limited): February 22, 2012

Workshop Cost: $25 (includes breakfast and box lunch)

Venue: Hilton Garden Inn Toronto/Burlington

Hotel Address:   985 Syscon Road, Burlington, Canada L7L 5S3

Hotel Telephone: 1-905-631-7000

First Name
Last Name
Work address
Work telephone
Email
Occupation	Select RN NP MD Other
Payment:

Cheques payable to: Lawson Health Research Institute (please indicate “Primary Care Diabetes Boot Camp” in the memo line)

Mail your cheque to:
Primary Care Diabetes Boot Camp
P.O. BOX 24038
London, ON N6H 5C4
Attn: Amanda Mikalachki

For more information or questions, please contact:
Tylene Fisher
Tel: 519-646-6000, ext. 67268
Fax: 519-858-5040
Email: diabetes.bootcamp@gmail.com

Please print this form for your records.

Please click on Submit to send this form.