Practical Pediatrics Conference
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PARTICIPANT REGISTRATION FORM

Section A - Participant Information
If you experience any technical difficulties when using this form or if you have registration questions, please contact us at skrobem@mcmaster.ca

The asterisk (*) indicates a required field.

Email Address*:
First Name*:
Last Name*:
Department*:
Institution/Hospital*:
Address Line 1*:
Address Line 2:
City/Town/Village*:
Province*:

Postal Code*:
Phone Number*: Ext:
Fax Number:
   
Please indicate if you have any dietary restrictions, requirements or allergies:
Note: if special meals are required at an extra cost, charges will be applicable.
   
Special Needs:
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Additional Comments:

 


Section B – Delegate Registration

I am a:

General Pediatrician
Pediatric Subspecialty – please specify:
Family Physician
Trainee – please specify:
Allied Health – please specify:

Primary area of practice (please check all that apply):

Community Based
Hospital Based
University Affiliated
Other – please specify:

How did you hear about this conference?

Brochure
Email
Workplace or Colleague
Internet Search
Attended Previous Conferences
Other – please specify:

 


Registration fees include: admission to all sessions, program syllabus, letter of attendance, breakfast, lunch and nutrition break.

  Early Bird Pricing
on or Before March 3, 2018
Regular Price
After March 3, 2018
Physicians
$160.00 $180.00
Other: Allied Health Professionals and Trainees not in a McMaster Pediatric training program (Students, Residents and Fellows)
$160.00 $180.00
McMaster Pediatric Residents and McMaster General Pediatric Fellows (Full Day – Lunch Included)
$160.00 $180.00
McMaster Pediatric Residents and McMaster General Pediatric Fellows (Half Day starting at 1:00pm – NO Lunch)
No Cost No Cost

Section C – Payment Information
Please verify all the information is correct. Your credit card statement will show this transaction as McMaster Pediatric Educational Conference.

Cancellation Policy
All cancellations must be received in writing no later than March 30, 2018 for a full refund, less an administrative fee of $50.00. No refunds will be issued after this date.

I acknowledge that I have read and accept the above conditions.

Section D – Participant Consent & Release Agreement
(Please scroll to the end and click on I AGREE after reading.)

CONSENT TO BE VIDEO RECORDED, AUDIO RECORDED, PHOTOGRAPHED, RECORDED AND/OR TO HAVE PUBLIC DISCLOSURE OF INFORMATION, AND WAIVER OF CONFIDENTIALITY FOR MEDIA PURPOSES.

I hereby give my permission and express written consent to Practical Pediatrics Conference (PPC) to digitally video record, videotape, digitally audio record and/or photograph me while I am attending and participating in the PPC. I further consent to PPC and its agents and assigns exhibiting, showing, re-producing, publishing, displaying, transmitting and other uses of all such video and audio recordings and photographic images in any media whatsoever in Canada or elsewhere, including presentations made for medical, scientific, educational and related marketing purposes.

I further acknowledge, confirm and agree that I shall have no right to inspect or approve any video and audio recordings and/or photograph(s) of me prior to it or their use by PPC or its agents and assigns in any manner and confirm and agree that I will receive no financial compensation arising from such use, including, without limitation, my providing services as a model.

I hereby fully and finally release PPC and its agents and assigns from any and all liability directly or indirectly arising out of the video and audio recordings and photographic images made and/or taken of me including, without limitation, how such recordings and images are used by PPC and its agents and assigns, the final form of such recordings and photographs and the timing, method and basis of it or their publication and distribution.

I acknowledge that PPC and its agents and assigns shall have the right to cancel any event offered or organized by PPC or its agents and assigns for which I may register to attend up to and including the day immediately prior to the scheduled commencement date of such event by email notification to me at the last email address I have electronically delivered to PPC. I hereby further release PPC and its agents and assigns from any and all claims relating directly or indirectly to such cancellation that I or my heirs, executors and administrators may have and hereby confirm and agree that PPC and its agents and assigns shall at no time be liable to me or my heirs, executors and administrators for any direct or consequential losses, damages, expenses or costs which I may suffer or incur as a result of a cancellation, including, without limitation, unnecessary travel expenses and loss of income.

WAIVER OF LIABILITY AND ASSUMPTION OF RISK ACKNOWLEDGEMENT.

In consideration of PPC permitting me to participate in any capacity whatsoever in the PPC (including but not limited to participation as an attendee or speaker), I hereby agree to the following terms:

  1. I expressly warrant and represent that by attending the PPC I am knowingly, freely and irrevocably assuming all risk while participating in and or attending the PPC, in any manner whatsoever, regardless of how, where or when I may incur or sustain any injury, damage or loss, and whether or not resulting from the negligence of PPC or otherwise.

  2. None of PPC or its directors, officers, employees, agents or consultants (the “Releasees”) shall be liable nor held responsible in law by me, or my heirs, executors, assigns and any legal or personal representatives for any physical bodily injury (including loss of life or limb), damage or other loss (including but not limited to economic loss) incurred by me, however sustained or incurred at any time during my participation or attendance at the PPC, including my travel time to and from the PPC.

  3. I hereby irrevocably release and hold the Releasees harmless in respect of any and all liability for and in respect of my physical injuries and/or economic loss derived from my participation and involvement, in any manner, in the PPC.

  4. Once I have agreed to this Participant Consent and Release Agreement, it will constitute a full answer and defence in favour of the Releasees in relation to any claim that I may advance against same for any physical injury, damage or loss sustained by me while participating in or attending the PPC.

  5. I understand that it is a condition of my participation in the PPC that I must agree to the terms of this Participant Consent & Release Agreement and that I am under no requirement or compulsion to participate or attend the PPC and I am free to decline participation if these terms are not acceptable to me.

  6. While attending the PPC I agree to abide by all rules posted or otherwise provided to me, as well as all applicable federal, provincial and municipal laws and regulations.

  7. I agree that regardless of actual causation, I am solely responsible for my safety while participating and attending the PPC.

I have read the foregoing Participant Consent & Release Agreement and confirm and agree that I fully understand its contents. I hereby warrant that I am of legal age and am competent to contract. I hereby provide and deliver both my express and informed consent as stated above and my agreement with the terms as outlined above by clicking on the I AGREE button as presented on this website and confirm that this Participant Consent & Release Agreement when given in this manner shall be forever binding upon me.

 

I agree to consent to have my name, address and email added to the mailing database for upcoming conferences: Yes    No


Press Submit to complete your registration.


If you experience any technical difficulties when using this form or if you have registration questions, please contact us at skrobem@mcmaster.ca


Already Registered?

If you have already registered but have not yet paid you can pay your registration fee here.

 

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