In-Person Registration Form
Please complete this form and click submit.
Name as per Travel Document:
*
Mr.
Mrs.
Miss.
Ms.
Dr.
Prof.
Prefix
First Name
Middle Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Other
Which clinic are you a member of?
*
Please Select
Michael G. DeGroote Pain Clinic Hamilton
Kingston Health Sciences Centre
The Ottawa Hospital Rehabilitation Centre
The Pain and Wellness Centre
McGill - Alan Edwards Pain Management Unit
St Anne - OSIC Pain Management Service
ChangePain
CBI headquarters
CBI - Victoria, BC
CBI - Calgary, AB
CBI - Edmonton, AB
CBI - Halifax, NS
CBI - Moncton, NB
CBI veterans
Lifemark - NB
Lifemark - NF
Lifemark - HQ
ACV
CPCOE
Other
Email:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Are you a veteran?
*
Yes
No
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Will your companion be attending as well?
*
Yes
No
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Companion's Travel Document Information:
*
Mr.
Mrs.
Miss.
Ms.
Dr.
Prof.
Prefix
First Name
Middle Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Other
Relationship:
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Will you require a hotel stay at the Sheraton Hotel Hamilton?
*
Yes
No
If you answered yes, please fill in the below:
Minimum 2 night stay is required
Check in date:
Please Select
Sunday, September 12th
Monday, September 13th
Check out date:
Please Select
Tuesday, September 14th
Wednesday, September 15th
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Will you require air travel?
*
Yes
No
If you answered yes, please fill in the below:
Preferred Airport:
Departure Date:
-
Month
-
Day
Year
Date
Return Date:
-
Month
-
Day
Year
Date
Will you require car transfers from:
Airport to Hotel only
Hotel to Airport only
Both ways
None
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Any special mobility request we should be aware of?
Will you be attending the Welcome Mixer on Monday, September 13th?
*
Yes
No
Do you have any dietary restrictions we should know about?
The Chronic Pain Centre of Excellence would like to gift you an clothing item. Please select your preferred size.
*
Please Select
S
M
L
XL
XXL
Submit
Should be Empty: