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

• June 4, 2018 Northern
• June 6, 2018 Eastern

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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:

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: