Non Member Registration Form

To register on-line, please complete the form below and click on submit at the end.  Please complete 1 form per person.

Note: if you prefer to print a form and to submit it by fax, please click here.

1 - Please enter participant information below. Do not use caps lock to fill out the form.
 
*FIRST NAME:
*LAST NAME:
TITLE:
ORGANIZATION:
DIVISION:
*ADDRESS:
P.O. Box/ Suite / etc.:
*CITY:
*PROVINCE:
*POSTAL CODE:
*TELEPHONE: FAX:
*E-MAIL:
2 - How did you hear about the conference?
Word of mouth
Mailing from FHNMA
Email message
Web site
Newspaper Ad
Other
3 - Registration Fee
The registration fee includes all business sessions, the opening reception on Tuesday evening, November 3, breakfast, lunch, 2 breaks and the reception and dinner on Wednesday, November 4 and breakfast, lunch and 2 breaks on Thursday, November 5, 2015.
Conference Early-Bird Rate (deadline for the early-bird is Friday, September 25, 2015):
FNHMA Non Member - $ 820
Conference Regular Rate (as of September 25, 2015)
FNHMA Non Member - $ 920
Reception and dinner ticket for guest
You may purchase a ticket for a guest for the Wednesday, November 4 Reception and Dinner ONLY
$125 Guest Name
Student (Full conference)
$175 - Rate for full-time students - student photo I.D. is required.

Are you GST/HST exempt? yes no
Note: If your Indian band is GST exempt, please provide us with a copy of you exemption certificate or letter.)

* Please check "yes" here if you would like to take advantage of a complimentary 1 year membership in FNHMA?

yes no

If yes, would you like to be included in the FNHMA’s Membership Directory? The directory allows you to network and share best practices with fellow First Nations Health Managers from across the country.

yes no

4 - Method of Payment (Your payment is required prior to the conference)
If you are paying by cheque:
1) Please make cheque payable to FNHMA
2) Mail a copy of your receipt and cheque to the
FNHMA Conference Secretariat (address below)

If you are paying by Credit Card:
1) Complete the credit card information requested below
2) We accept MasterCard and Visa ONLY

5 - Payment
Please select method of payment Cheque
  Credit Card (MasterCard and Visa ONLY)
Registration Fee:
5% GST:
Total:
Cardholder Name:
The FNHMA HST/GST number is 811344852
Credit Card Number:
Format - no spaces or dashes between numbers
Expiry Date:
Format mmyy (example: 0712)

Your registration will be processed and confirmation of registration will be sent to you by email.

6 - Cancellation / Substitution
Cancellation of registration should be sent in writing by email. Cancellations will be accepted until September 25, 2015 for a full refund. A $300 cancellation fee will apply for cancellations received between September 25 and October 2, 2015. No refund for cancellations received after October 2, 2015 and no refund for no-shows at the conference. Substitutions are accepted at any time.
7 - Contact Us
If you have any questions about the conference, please contact Micheline Bélanger at the FNHMA Conference Secretariat.

Tel: (819) 827-5931 or toll-free (866) 775-1817
E-mail: conference@fnhma.ca

Mailing address:
FNHMA Conference Secretariat
40 chemin du Roc Est
Chelsea, Québec
J9B1T1