BC-CfE Update Pre-Registration Information
Disclaimers
(
*
) Denotes a required field
First Name
Last Name
Credentials (ie. MD, PhD)
Principal Role with respect to HIV/AIDS care:
Family physician
Other Physician:
Nurse Practitioner
Nurse
Pharmacist
Dietitian
Social worker
Community worker
Policy maker
Researcher
Medical resident
Student (health focus)
Other role:
Please Specify:
Region/Health Authoritycurrently working in:
Interior
Providence Health Care
Fraser
Provincial Health Service Authority
Vancouver Coastal
First Nations Health Authority
Vancouver Island
Northern
Not applicable
Work Details
*
Primary Place of Work:
Department:
Suite/Room Number:
*
Street Address:
*
City:
*
Country:
Canada
*
Province:
British Columbia
*
Postal Code:
*
Telephone:
Fax:
I plan to attend
in person
via webcast
Contact information
Health Authority or institutional email preferred (no gmail, hotmail...)
*
Email:
*
Confirm Email:
Mobile phone:
Please note: This form is for pre-registration only. Once submitted, your registration is not yet confirmed. You will receive a notice of confirmation
with a registration number
at a later date.