New Customer Registration Form

Centre Name*
Contact Name*

First NameLast Name
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Phone Number*
E-mail*
example@example.com
Length of Workshop*
Topic or Workshop you are looking for.*
Be as specific as possible.
Location of your PD event?

At our programWould like MCCA to book the venueWould like to come to MCCA for our PD
Date Requested - 1st Choice*

MonthDayYear
Date
Date Requested - 2nd Choice*

MonthDayYear
Date
Date Requested - 3rd Choice*

MonthDayYear
Date
Do you have a data projector/Screen or Blank Wall?

YesNoOther
What is your budget for your PD event?*
Note: Cost of a personalized PD varies. Please note the starting (1/2 day) cost of a pd is $500.00 and can vary depending on the speaker and fees.
Terms & Conditions
By requesting a Personalized PD event, the centre or organization agrees to the following terms:

MCCA will coordinate all aspects of the event, including recruiting and contracting the presenter, issuing presenter payment, providing handouts (if applicable), distributing participant certificates and evaluations, and issuing an invoice. A data projector may be provided, subject to availability.

An invoice will be issued to the centre once the presenter and workshop are confirmed, and payment is due upon receipt. Payments may be made by cheque, E-transfer, Visa, or Mastercard.

Personalized PD events are intended for staff of the contracting centre or organization only. Workshop spots may not be sold or offered to other centres or organizations, unless approved by MCCA.

If the event is cancelled for any reason, a $250 cancellation fee will apply. MCCA will make reasonable efforts to reschedule the event where possible.

By signing this you confirm that you have selected MCCA to coordinate and plan your professional development event and are not seeking to secure your own presenter at this time.
I understand the Terms & Conditions

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Terms & Conditions