2019-03-06_ruthkathleenpelletier_Final-Registration Form - April 9th 2019 Conference RP March 5th date cor (1).pdf

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A SENIORS NETWORK… FOR SENIORS…BY SENIORS  
 
Conference  
Responding Positively  to Life’s Changes:  Caregivers Finding Balance  
April 9th, 2019   8:30 A.M - 4:00 P.M.  
Ramada Plaza Montr éal 
6445 Boul. D écarie, Montré al, QC. H3W 3E1  
 
Registration Form * 
Deadline to receive cheque and form March 27th, 201 9                
Please Print:  
 
Name : _____________________ _ ______________ ___________  
 
Address:  ____ ______________________________________  
 
Telephone: ____________ _____               Cell:  _________________ _______  
 
Email:  _____________________________________________  
 
Payment can be made Online at: www.seniorsactionquebec.ca  
 
Payment made : $ __________ _ Indicate if Individual / Kiosk _________  
                
*If paying by cheque include copy of registration form , cheque  & mail to :  
 
Seniors Action Québec  
1857 Du Maisonneuve Ouest,  Suite #304,  Montr éal, QC. H3H 1J9  
 
Indicate on Cheque Memo Line: Conference Registration OR Kiosk  
 
*When you pay online email  a copy of  the registration form to:  
ruthkathleenpelletier@gmail.co m 
 
*PLEASE INDICATE FOOD ALLERGIES & DIETARY RESTRICTI ONS  
 
______ _____________________________________________ ___________