Home > Preceptorship > Interprofessional Preceptor Workshop Registration Form

Preceptor Workshop Registration Form

*

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

  • March 26, 2020 Central - Cancelled
  • April 23, 2020 Central - Cancelled
  • May 1, 2020 Central - Cancelled
  • May 27, 2020 Central - Cancelled
  • June 17, 2020 Central
  • September 23, 2020 Central 
  • October 28, 2020 Central
  • November 17, 2020 Central
  • November 18, 2020 Central

 

  • April 1, 2020 Eastern - Cancelled
  • April 30, 2020 Eastern
  • June 5, 2020 Eastern
  • June 12, 2020 Eastern

 

  • April 7, 2020 Northern
  • May 5, 2020 Northern

 

  • April 24, 2020 Western - Cancelled
  • May 15, 2020 Western - Cancelled
  • May 22, 2020 Western - Cancelled
  • September 24, 2020 Western
  • October 22, 2020 Western
  • November 19, 2020 Western

 

 

*


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

*

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

*

Home Phone:

Work Phone:

*

Email:

Professional Designation:

 

Health Authority:

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

Other:

*

Facility:

*

Practice Setting:

*

Health Services Manager Name:

*

Health Services Manager Email: