Paraspinal IGRT Education Course

Accelerated Education Program

Registration Form

Once completed, please return to AEP Education Coordinator:

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First Name:
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Profession: Select a Profession...Radiation OncologistMedical PhysicistRadaiation Therapist/DosimetristAccelerator Services/TechnicianEngineerRegulatorTrainee (Pre-Certification)Other
If “other”, please indicate here:
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If applicable, please provide promotional code:
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1.Please check which course you would like to register for:

2.A social eventhas been organized during the course. Please indicate if you will attend:

a.Social Event Tuesday Night (Details to follow)Yes No

3.AEP is “going green as of 2015”, and will no longer be providing printed course presentations and binders; and will instead be providing electronic copies of presentations prior to the course. You will receive a bound copy of the course program with session descriptions.

*Please indicate if you would like a printed binder at $25 per binder. Yes No

Resume Template

Participant Credentialing

It is a requirement of University Health Network/Princess Margaret Cancer Centre that visitors receive Observership Credentialing to be permitted access to our facilities. In order for us to obtain this status, we require you to complete the Resume Template attached or submit your Curriculum Vitae.

(A minimum of two weeks is required to process this application.)

You must either complete this form or submit a current CV.

Name

Credentials
Business Address
Education
Year of Graduation
CurrentHospital and University Appointments

Registration Terms & Conditions

PLEASE READ THESE TERMS AND CONDITIONS CAREFULLY AS IT CONTAINS IMPORTANT INFORMATION

By signing this registration form you are agreeing to the following terms and conditions.

I understand that photographs and/or videos may be taken during the course, and may be used by AEP for marketing and promotional purposes in the future. I consent to have my photo taken.

Yes, I consent

No, I do not consent

We require your consent to be added to the AEP Mailing List in order to receive important pre and post-course information and materials. This mail list is also used for notifications of future AEP course offerings and opportunities. You may unsubscribe from this list at any time following the completion of a course.

Yes, I consent

No, I do not consent

By signing below, you acknowledge that you will participate in this course in the spirit of academic exchange; that any differences of opinion with course faculty members (or fellow attendees) will be considered in the context of a learning environment and where necessary, clarification be sought with the individual allowing them the opportunity to discuss any content and/or expressed ideas with you before you leave.

Please sign here acknowledging the above terms and conditions.

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