2005 REGISTRATION

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2005 REGISTRATION Powered By Docstoc
					                                                            10th Annual Alberta Health & Safety Conference and Trade Fair
                                                            2011 DELEGATE REGISTRATION FORM
DELEGATE INFORMATION
LAST NAME                                                                  FIRST NAME

COMPANY                                                                                                                       TITLE

ADDRESS                                                                    CITY, PROVINCE                                     POSTAL CODE

PHONE                                                                                              FAX

                                                                                                   May we release your contact information to
EMAIL
                                                                                                   our Exhibitors & HSCSA Board members?                Yes     No
 I WOULD LIKE A 3-DAY C-TRAIN PASS (COST IS $ 18.00)                                                                    YES                         $                 -
PROFESSIONAL DEVELOPMENT COURSES (see website for more information)
CHECK THE PDC
 COURSES YOU                  PDC01 - CRSP Exam Preparation Course                              PDC02 - PPE Bootcamp
WISH TO ATTEND                                                                                                                                      $                 -
CONFERENCE DETAILS
CHOOSE
ONE           Regular 3-day Registration                                                                                                            $          550.00
SCHEDULE - Monday, October 24
9:00 - 11:00        Fun Run - proceeds to Threads of Life                               I will participate                                          $                 -
11:00 - 12:30       Delegate Check In (Delegates are on their own for lunch) & Trade Fair Opens

12:30 - 2:00        Keynote Address - Michael Kerr                        I will be attending

2:00 - 3:00         Choose your session        CHOOSE FROM DROP DOWN
3:00 - 3:45         Coffee Break in Trade Fair Area

3:45 - 4:45         Choose your session        CHOOSE FROM DROP DOWN

Welcome Reception - 4:45 - 7:00 pm (included with Full Registration)                                  I will be attending

                    I would like to order extra Reception Tickets ($ 20/ticket)                    Number of tickets                                $                 -

SCHEDULE - Tuesday, October 25
8:00 - 8:30         Registration & Trade Fair Opening

8:30 - 10:00        Choose your session        CHOOSE FROM DROP DOWN

10:00 - 10:30       Coffee Break in Trade Fair Area

10:30 - 11:30       Choose your session        CHOOSE FROM DROP DOWN

11:30 - 1:00        Lunch & Trade Fair Viewing

1:00 - 2:30         Keynote Panel Discussion - If I Knew Then What I Know Now                     I will be attending

2:30 - 3:15         Coffee Break in Trade Fair Area

3:15 - 4:15         Choose your session       CHOOSE FROM DROP DOWN


SCHEDULE - Wednesday, October 26
8:00 - 8:30         Registration & Trade Fair Opening

8:30 - 9:45         Keynote Session - Don Lowry           I will be attending

9:45 - 10:30        Coffee Break in Trade Fair Area                                                                           Subtotal              $          550.00
10:30 - Noon        Choose your session        CHOOSE FROM DROP DOWN
                                                                                                                              GST (87485 3419)      $            27.50
12:15 - 1:15        Choose your session        CHOOSE FROM DROP DOWN                                                          TOTAL DUE             $          577.50
1:15 - 2:15         Sit down Lunch with Clint Dunford         I will be attending                                             Payment Type - please choose
2:15 - 3:30         Closing Ceremonies & Keynote Address - Dr. Nedd                     I will be attending                    CHEQUE / MONEY ORDER

CREDIT CARD
                                                                                                                               Please remit your cheque to HSCSA, BOX
INFORMATION                                I would prefer to be contacted for my credit card information
                                                                                                                               38009, CALGARY, ALBERTA, T3K 5G9 to
Card Number                                                                                                                            complete your registration

                                                            Cardholder
Expiry Date
                                                            Name                                                               THANK YOU FOR YOUR REGISTRATION !
                                                            ___________                                                          Fax completed forms to (403) 206-7099




                           CANCELLATIONS—All requests for cancellation and refunds must be received in writing at the
                            HSCSA office by September 1, 2011. Refunds will be deducted a 20% administration fee. No
                                   refunds will be issued after that date. Substitutions will gladly be accepted
PHOTO RELEASE
Please note that by completing the Delegate Registration form, you give the Health and Safety Conference Society of Alberta (HSCSA) permission to use photos taken
of you participating in the upcoming Health and Safety Conference of Alberta conference and tradeshow for the purpose of promoting the conference. Some photos
may be close-ups and others may be from a distance. Promotion of the tradeshow may include brochures, posters, the HSCSA website and other media.

Please note that if you do not want your photo included in any of the Conference’s promotional material, please request that the photographer delete the particular
photo immediately. Otherwise, it is implied that you do give permission for your photo to be used to promote the HSCSA conference




                                                            Other (please indicate):




                                                            YEARS EXPERIENCE IN H & S FIELD




                                                            PROFESSIONAL SOCIETY MEMBER
Other (please indicate):




CERTIFICATION HELD


                                                            Other (please name)




                                                            Purchasing Role:
                                                            Union Member:
                                                            Safety Committee Member:                                          Other (please name)

Other (please indicate):                                                                                                                            0

				
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