registration_form

First name *
Last name *
Position title *
Organisation *
Address*
City *
Province *
Postal Code *
Phone *	Ex.
Fax
Email *

Conference Selection:

Please select which conference you wish to attend on each of the following scheduled periods.

Friday, September 17^th, 10 h 30	1^st choice	2^nd choice
3A : Vehicle Design for the future: Considerations for an aging population
3B : Developing a training protocol for driving a vehicle for people having undergone a stoke

Friday, September 17^th, 11 h 15	1^st choice	2^nd choice
4A : The evaluation of driving capacities at the SAAQ
4B : In-simulator training of driving abilities in a traumatic brain injured patient

Friday, September 17^th, 13 h 15	1^st choice	2^nd choice
5A : How could we help older drivers to increase their driving performance?
5B : The effects bracing a lower limb has on driving.

Special needs? *

Yes No

Yes, precise :

Registration fee

Spouse Fee - for meals only

If your spouse will be joining you for meals on September 16^th & 17^th, 2010, the following fees are required for ‘spouse’ registration. Includes cocktail reception, all meals & breaks. Conferences are not includes

Please include spouse’s name:

National Workshop & NMEDA Canada Conférence
	Participant	Participant + spouse
Early bird (before July 1^st)	275$	425$
After July 1^st	325$	500$
For one day	200$	375$
Students	200$	375$

Registration total*

Paiement

Please send cheque payable to “Institut de réadaptation en déficience physique de Québec” to:

Institut de réadaptation en déficience physique de Québec
c/o Secrétariat - Formation réseau
525 Wilfrid-Hamel Bvld. Room H-200
Québec (Qc) G1M 2S8

Your registration fees are confirmed by the date we receive your payment.

Your registration is confirmed and ensured once we receive payment.

Cancelation & substitutions

The registration fees are non-refundable. Registration can be substituted without

additional charges, if notice is given.

I agree with the cancellation and substitution policy.

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