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)

Yes, I wish to subscribe
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.
Please choose only ONE registration type (Credit Card or Other)

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

Credit Card Registration

Regular$240.00CAD

Seniors (65+ or Retired)$120.00CAD

Students (Non-Collaborative Specialization)$120.00CAD

Total $0.00CAD

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

Other Registration Types

Practicum Supervisors of MSW Gerontology Students (FREE)Students Registered in ILCA Collaborative Specialization (FREE)4th Workshop FREE (discount for a registrant signing up for 4 workshops in the same academic year)4th Registrant FREE (discount for groups of 4 from the same organization who are signing up for the same workshop)
Should be Empty: