Pacific Coast Brain Injury Conference, Vancouver BC Canada

Pacific Coast Brain Injury Conference

Registration Form

Printable Registration Form (PDF)

Is this your first time attrending the conference Pacific Coast Brain Injury Conference?:	Yes No

Attendee Information
First Name:
Last Name:
Company/Affiliation:
Address:
City:
Province/State:
Postal/Zip Code:
Country:
Phone:	Area: Phone: Ext:
Fax:	Area: Phone:
Email:
Are you a presenter?:	Yes No
Dietary Restriction (if any):

Do you require assistance for your meals?
(We will arrange a volunteer to assist you.)

Yes No

Registration Categories & Rates
Web Registration Rate
A. Full Conference February 16 & 17
Full Conference:	$550.00
Pre-Conference Day & Full Conference:	$695.00
Student:	$350.00
	None

B. Partial Conference & Pre-Conference Day
Friday, February 16:	$275.00
Saturday, February 17:	$275.00
February 15 - Pre-Conference Prevention Workshop:	$195.00
February 15 - Pre-Conference Human Relations Workshop:	$195.00

SURVIVOR OR FAMILY MEMBER RATE: Are you a survivor or family member requesting a subsidy? Deadline for subsidy application is December 1, 2006. Contact Janelle at (250) 592-4460 or click here for more information.

C. Additional Lunch or Social Reception Tickets
Lunch is included for the day(s) that you have registered.
Thursday Lunch ($35.00 ea.) Friday Lunch ($35.00 ea.) Saturday Lunch ($35.00 ea.) Friday Social Reception ($45.00 ea.)

D . Session Choices
View Thursday Sessions
View Friday Sessions
View Saturday Sessions

Thursday	Friday	Saturday
Pre-Conference
Prevention Human Relations: 2A Human Relations: 2B Human Relations: 2C
Medical/Research
	MR-1 MR-2 MR-3 MR-4 MR-5 MR-6	MR-7 MR-8 MR-9 MR-10
Concurrent Sessions
	Opening Plenary A-1 A-2 A-3 A-4 A-5 B-2 B-3 B-4 B-5 C-1 C-2 C-3 C-4 C-5 D-1 D-2 D-3 D-4 D-5	Saturday Morning Plenary E-1 E-2 E-3 E-4 E-5 E-6 Saturday Lunch Plenary F-1 F-2 F-3 F-4 F-5 F-6 Closing Plenary

E. Additional Information
Kindly complete the information below. This assist us with planning future conferences.

Please check all that apply. You are a:
Survivor	Family Member
Educator	Service Provider
Goverment Rep	Lawyer
Caregiver	Fee Payer
Rehab Professional	Medical Professional
Insurer	Other

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