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 group 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
Lifemark - NB
Lifemark - NF
Lifemark - HQ
Advisory Council for Veterans
Internal CPCoE Staff
Researcher
Scientific Advisory Board
IRP Health
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 member of our Advisory Council for Veterans??
*
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 Bonaventure Hotel in Montreal?
*
Yes
No
If you answered yes, please fill in the below:
Maximum 3 night stay
Check in date:
Please Select
Sunday, October 2nd
Monday, October 3rd
Check out date:
Please Select
Tuesday, October 4th
Wednesday, October 5th
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Will you require air travel?
*
Yes
No
If you answered yes, please fill in the below:
Preferred Departure Airport:
Departure Date:
-
Month
-
Day
Year
Date
Return Date:
-
Month
-
Day
Year
Date
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Any special mobility request we should be aware of?
Will you be attending the Welcome Dinner on Monday, October 3rd?
*
Yes
No
Do you have any dietary restrictions we should know about?
Submit
Should be Empty: