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Preceptor Workshop Registration Form

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

  • October 25, 2019 Northern
  • October 30, 2019 Central
  • January 16, 2020 Western
  • January 30, 2020 Central
  • February 19, 2020 Central
  • March 26, 2020 Central
  • April 24, 2020 Western
  • May 8, 2020 Western
  • May 15, 2020 Western

 

 

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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:

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

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: