Home > Preceptorship > Interprofessional Preceptor Workshop Registration Form

Preceptor Workshop Registration Form

*

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

  • October 31, 2018 Western
  • November 14, 2018 Eastern
  • November 14, 2018 Western
  • November 30, 2018 Western
  • January 31, 2019 Central
  • February 20, 2019 Central
  • March 19, 2019 Western
  • April 30, 2019 Western
  • June 6, 2019 Western

 

 

*


First Name (This is the name that will appear on your certificate):

*

Last Name (This is the name that will appear on your certificate):

*

Home Phone:

Work Phone:

*

Email:

Professional Designation:

 

Health Authority:

NSHA - Eastern NSHA - Central NSHA - Northern NSHA - Western IWK

Other:

*

Facility:

*

Practice Setting:

*

Health Services Manager Name:

*

Health Services Manager Email: