2019-03-06_ruthkathleenpelletier_Final Registration Form - June 13th 2019 Conference March 5th RP-LB (1).pdf

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A SENIORS NETWORK… FOR SENIORS…BY SENIORS  
 
Conference  
Geriatric Healthcare Professionals and Seniors Talking Together About 
Seniors Needs.  
June 13th , 2019   8:30 A.M - NOON  P.M.  
Ramada Plaza Montr éal 
6445 Boul. D écarie, Montré al, QC. H3W 3E1  
 
Registration Form * 
Deadline to receive cheque and form  May 30th , 201 9                 
Please Print : 
 
Name : _____________________ _ ______________ ___________  
 
Address:  ____ ______________________________________  
 
Telephone: ____________ _____               Cell:  _________________ _______  
 
Email:  _____________________________________________  
 
Payment can be made Online at: www.seniorsactionquebec.ca  
 
Payment made : $ __________ _ Indicate if for an Individual  or Kios k _________  
                
*If paying by cheque include copy of registration form , cheque  & mail to :  
 
Seniors Action Quebec  
1857 Du Maisonneuve Ouest,  Suite #304,  Montreal, QC. H3H 1J9  
 
Indicate on Cheque Memo Line: Conference Registration OR Kiosk OR Sponsorship  
 
*When you pay online email  a copy of  the registration form to:  
ruthkathleenpelletier@gmail.com  
 
*PLEASE INDICATE FOOD ALLERGIES & DIETARY RESTRICTIONS.  
 
 
______ _____________________________________________ ___________