Registration Form

REGISTRATION FORM
Please complete ALL fields before submitting

GENERAL INFO

FIRST NAME:
LAST NAME:
GENDER:	M F
DATE OF BIRTH (month/day/year):
PHONE:
FAX:
E-MAIL:
ADDRESS:
CITY:
PROVINCE:
POSTAL CODE:
TRAINING PROGRAM:
PGY:

ABSTRACT
Will you be submitting an abstract?:	Yes No

REGISTRATION FEES

Regular Package includes:

Transportation to and from Toronto

3 nights hotel accommodations (double occupancy)

Two-day scientific symposium

Breakfasts, lunches & health breaks

Friday evening Cocktail party

Gala banquet & awards ceremony Accommodation Package includes:

3 nights hotel accommodations (double occupancy)

Two-day scientific symposium

Breakfasts, lunches & health breaks

Friday evening Cocktail party

Gala banquet & awards ceremony Toronto Residents Package includes:

Two-day scientific symposium

Breakfasts, lunches & health breaks

Friday evening Cocktail party

Gala banquet & awards ceremony

Category	Late Registration (July 2 - August 1)	Optional (at an additional fee)
Regular Package:	$350.00	Additional hotel nights: $220.00 per night
Accommodation Package:	$200.00	Spouse/Guest hotel nights: (or additional fee to have your own room): $100.00 per night
Toronto Residents Package:	$75.00	Additional Gala banquet tickets (Saturday): $50.00 per ticket
TOTAL COST:

Cancellations received after August 1, 2004 are nonrefundable. $25.00 fee for non-sufficient fund cheques. Payable to the Canadian Orthopaedic Residents Association.

Roommate Preference (if none indicated, one will be assigned!):

TRAVEL INFORMATION
The scientific symposium will begin on Friday morning, November 5th and end on Saturday night, November 6th. Residents who wish to attend the entire CORA meeting should request to arrive on Thursday, November 4 and depart on Sunday, November 7.

Airport of Departure:
Aeroplan #:
Airmiles #:
Preferred arrival date (month/day/year):
Departure date (month/day/year):
Special travel requirements:

CREDIT CARD INFORMATION

Type of card:
Name of cardholder:
Card number:
Expiry date:

Thank you for registering! A confirmation of receipt will be e-mailed to you within 48 hours.