REGISTRATION

Primary Health Care Research Day- Trillium 2013
Westin Harbour Castle, Toronto
June 19, 2013

DEADLINE: Friday, June 7, 2013

Please note: we recognize that payment by cheque may be delayed past the registration deadline of June 7th, 2013. We will follow up if payment is not received by June 15^th.

REGISTRANT INFORMATION:
Title:	Select one Dr. Mr. Mrs. Miss Ms.
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Status:	Researcher Clinician Administrator Graduate Student Resident       (For Graduate Students and Residents: Limited travel grants available        based on geographical representation) Other, please specify
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CONFERENCE DETAILS:
Main Discipline: Please specify discipline: Please select a Workshop: ( 2:40pm - 4:00 pm ) Workshop #1: On the Applications of Time Series Methods in Primary Care and Health Services Research Facilitator: Dr. Rahim Moineddin, University of Toronto. Affiliate Scientist at Institute for Clinical Evaluative Sciences (ICES) Workshop 2: Social Network Analysis: An Introduction to Concept, Development and Delivery Dr. Anita Kothari, School of Health Studies, Western University Undecided
REGISTRATION FEES:
Registration Fee: Please select appropriate fee   Presenting Non-Presenting Attendee $70.00+HST=$79.10 $85.00 + HST = $96.05 Resident/Student Free if Lead Presenter  ** Limited travel grants are available for (lead) Student/Resident presenter. $50.00 + HST = $56.50
I will pay registration costs by: Cheque (payable to "The University of Western Ontario") Credit Card (Click here to obtain copy of form to fill out and FAX back to us)                       (Mastercard or Visa only) Did you submit an abstract? Yes, I have already submitted an abstract. I will be sending in my abstract. No I am NOT submitting an abstract Undecided Verification Submission Code: Please enter the text you see in the image. Make sure you enter it exactly as you see it(upper and lower case). This is required to prevent us from getting spam submissions. Then press the Submit button to send your form. Thank you.