Course Registration Form

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Course Registration Form

DISCLAIMER: Please note that the event is going to be photographed and pictures may be used for publication by the Department of Otolaryngology Head & Neck Surgery.听 Please write听in the comments section of your registration, if you听disagree听with having your/your family photos published or send me an email no later than March 4, 2025.

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Registration Fee*:

Early registration (before January听3, 2025) is $550 CDN听
Late or on-site registration is $650听CDN听

Registration for residents and fellows is free. (Medical students interested in attending must contact Fabio Ciccocioppo听at otlhns.med [at] mcgill.ca)

* It is important to note that the registration fee does not include dinner for your companion or children. Saturday dinner tickets for your companion and children may be purchased on site at the following costs:

Adult 18 yrs old and over - Price $100 CDN听

Children 12 to 17 yrs old听 - Price $60 CDN听

Children 6 to 11 yrs old - Price $30 CDN听

Young children 0 to 5 yrs old - free

Note:

WE ACCEPT CREDIT CARDS FOR COURSE REGISTRATION.
YOUR REGISTRATION WILL BE CONFIRMED UPON RECEIPT OF YOUR PAYMENT.
The registration fee includes a Saturday buffet dinner for the registrants.
Saturday buffet tickets for companions and family members may be purchased on site.
Registration fee does not include Saturday Night dinner for your companion.
Friday Night includes听WELCOMING COCKTAIL for all participants, companions and family members
Any requests for refund of registration cost must be received in writing prior to the start of the meeting and will be subject to a $50.00 CAD administration fee.

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PAYMENT METHOD

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Payment by Credit Card:

Please fill out the registration form below and call : 514-934-1934 ext.36386 with your credit card in hand, Tuesdays to Thursdays from 9:00 am to 4:00 pm to make the payment.

Payment by Cheque:

Please fill out the registration form below and send by mail along with cheque payable to "MUHC" to the following address:

Fabio Ciccocioppo - Registration Coordinator

Department of Otolaryngology - Head and Neck Surgery

平特五不中 Health Centre - Glen Site

1001 Decarie Blvd., Room D05.5639

Montreal, Quebec (Canada)

H4A 3J1

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Title:

First Name: *

Last Name: *

Address: *

City: *

Prov/State: *

Postal/Zip Code: *

Country: *

Telephone: *

Email: *

Fax:

University affiliation:

Hospital affiliation:

If a 平特五不中 OTL alumnus, please indicate year

Number of Participants attending the Course *

Number of Adults 18 plus (including yourself)

Number of Children ages 1 to 5

Number of Children ages 6 to 11

Number of Children ages 12 to 17

Please indicate if you are still in training (resident or fellow)

Method of payment *

Cheque

Credit card

I am a Resident/Fellow

Call 514-934-1934 ext.36386 with your credit card in hand, Mondays to Fridays from 9:00 am to 4:00 pm to make the payment.

Send by mail along with cheque payable to听"MUHC Account #65689"

Comments:

Leave this field blank

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平特五不中

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