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Preceptor Workshop Registration Form

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Choose a Workshop:


 Foundational / Level One Workshop

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Date of Workshop: (Please select one date per form)

  • July 19, 2017 - Yarmouth, NS 
  • September 14, 2017 - Liverpool, NS
 July 19, 2017
 September 14, 2017

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First Name (This is the name that will appear on your certificate):

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Last Name (This is the name that will appear on your certificate):

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Street Address:

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City:

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Province:

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Postal Code:

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Home Phone:

Work Phone:

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Email:

Professional Designation:


 Lab Tech.
 LPN
 OT
 RN
 RSW

Other:

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Years of Experience:

Health Authority:

NSHA - Eastern NSHA - Central NSHA - Northern NSHA - Western IWK

Other:

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Facility:

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Practice Setting: