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Preceptor Workshop Registration Form

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

  • September 23, 2020 Central - Full
  • October 28, 2020 Central - Full
  • November 17, 2020 Central
  • November 18, 2020 Central

 

  • September 24, 2020 Eastern (CBRH 0800-1200)
  • September 24, 2020 Eastern (CBRH 1230-1630)
  • October 30, 2020 Eastern (SMRH 0800-1200)
  • October 30, 2020 Eastern (SMRH 1230-1630)
  • November 26, 2020 Eastern (NSGH 0800-1200)
  • November 26, 2020 Eastern (NSGH 1230-1630)

 

  • September 24, 2020 Western - Full
  • September 29, 2020 Western (AV, Chipman Building)
  • October 5, 2020 Western (SSRH)
  • October 14, 2020 Western (YRH) - Full
  • October 22, 2020 Western - Full
  • November 19, 2020 Western - Full

 

 

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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: