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Preceptor Workshop Registration Form

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Date of Workshop: 

  • October 14, 2020 Western (South West)
  • October 22, 2020 Western (South Shore)
  • November 19, 2020 Western (Annapolis Valley)

* To register for Cape Breton area workshops click here.
* To register for workshops based in St. Martha's please email Julia.Kolanko@nshealth.ca

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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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Home Phone:

Work Phone:

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Email:

Professional Designation:

 

Health Authority:

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

Other:

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Facility:

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Practice Setting:

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Health Services Manager Name:

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Health Services Manager Email: