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Mixer 2007 Registration Form

Registration Information

Complete the following registration form for the 2007 Mixer Conference.

Part 1: Personal Contact Information

First Name:

Last Name:

Birth Date:

Age:

Gender:

Street Address:

Apartment Number:

City:

Province:

Postal Code:

Phone Number:

() - ext:

Email:

Part 2: Registration Type

Registering As:

Associated University:

If Other, Please Specify:

Payment Method:

Part 3: Travel and Housing Information

Your Mode of Transportation ARRIVING at Conference:

Expected Date and Time of Arrival:

at :

Cell Phone Number at Conference:

() - ext:
 

Your Mode of Transportation LEAVING the Conference:

Expected Date and Time of Departure:

at :

 

Do You Require Billeting/Hotel Accommodations?

If Yes, Which Accommodation Do You Require?

 

The EMRG Team has been working hard to provide accomodations at the Centennial College Residence and Conference Centre for an economical rate. The hotel is just minutes away from UTSC and all the necessary amenities are included. Please call 416-438-2216 to book your room and reference "ACERT Mixer Conference" to obtain the group rate deal of $69.95 per room (four occupants per room). A credit card would be needed to place a hold on the room.

Centennial College Residence and Conference Centre
940 Progress Avenue
Toronto, Ontario  M1G 3T5

Part 4: Emergency Contact

Full Name:

Relation to You:

Phone Number:

() - ext:

Email:

Part 5: Medical Conditions and Information

Do You Have Any Dietary Needs? (i.e. Vegetarian, Vegan, etc.):

Do You Have Any Allergies or Medical Conditions?

Do You Require Any Special Assistance? Explain:

Part 6: Competition Day

Notes:

Please provide your top three choices for competition day.

You can only judge at the competition if you have the ACERT Judging Certification or are deemed eligible to judge by ACERT. For further information, please email judgingert@acert.ca for more details.

First Choice:

Second Choice:

Third Choice:

Additional Information

Payment Requirements:

If you are a current or alumni member of an ACERT Member Team, a confirmation email will be sent to your school's team (to the ACERT Team Representation or Team Director) for all registrations from your school once payment has been received. If you are not affiliated with an ACERT Member Team, a confirmation email will be sent to you directly once payment has been received. Regular Registration by Monday, October 22nd, 2007 is $70 per person.

Note that your registration is not complete until your payment has been received. We accept cheque only for payment at this time. If you are interested in providing payment online through credit card, please contact Allen at finance@emrgatutsc.com. You will be contacted regarding payment procedures. Please be aware that service charges will apply to online payments. Cheques should be made payable to the "Emergency Medical Response Group at UTSC" with "Memo: Mixer Delegate Fee".

Mailed Cheques should be post dated by the deadline of registration.

Please Send Payment To:

Emergency Medical Response Group at UTSC
Bladen Wing  BV-306
1265 Military Trail
Toronto, Ontario  M1C 1A4

Refunds:

Refunds will be handled on an individual basis and are at the discretion of the planning committee.

Final Notes:

A copy of this registration form will be sent to your email address.

See you at the 2007 Mixer Conference!