Excelling as a Nurse Leader Registration Form

Excelling as a Nurse Leader in Long Term Care

2010 Registration Form

Please choose one of the following Program locations:

Please provide the following information for all staff to be registered:

(Registrant names must be submitted at one time to qualify for home(s) discounts.)

	Names	Registrant's Email	Organization's Name
1.
2.
3.
4.
5.
6.

Manager Contact Name(s)

Manager Email(s)

# of Participants: @ = Total

Fee Structure
1 - 4 people = $587.60 each (all taxes included)
5 or more people =$542.40 each (all taxes included)

Please make cheque or money order payable to: Silver Meridian

Mailing Address: 

City  Prov.P.C.
Facility Phone  Fax