ILCA Workshop Registration Form

Title
Full Name

First NameLast Name
The following information is for your letter of completion:
Position Title
Organization
Organization's Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Information regarding the workshop will be tied to this e-mail
E-mail
Subscribe to the Institute's emailing list to receive regular communications for upcoming events (optional)
How did you hear about this workshop?
Phone Number

Area CodePhone Number
Workshop Attending
Select from drop down menu
If you have an existing UofT student/faculty/staff utorid, please enter it here (for registration to Quercus) (temporary guest utorids excepted)
If you've previously received a temporary guest utorid for another workshop that begins with qq, you do NOT need to enter it here.
Payment

Please choose only ONE registration type (Free, if applicable, or Credit Card)

The following two discounts are available and can be selected below in the Other Registration Types section:

Pay for 3 & the 4th is FREE when registering a group from your organization in the same workshop
Individuals registering in 4 workshops in the same academic year are also eligible for the Pay for 3 & the 4th is FREE promotion

Regular$240.00 CAD

Seniors (65+ or Retired)$120.00 CAD

Students (Non-Collaborative Specialization)$120.00 CAD

FIFSW Gerontology Students - during the first year after graduation$120.00 CAD

Total $0.00 CAD

Credit Card (VISA or MasterCard only)
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year