Childhood Cancer and The Family

Childhood Cancer and The Family - Together in 2000
Registration Form

Please complete the following:

First Name:                                                                                 Last Name:

Address:

City:                                                                                                Province/Country:

Postal Code:                                                                               Phone Number:

If other family members are attending, please print their names as preferred for the conference name badge.




Part I: REGISTRATION CATEGORIES AND FEES

Category	Early Bird - Postmarked before May 1, 2000	After May 1, 2000 and onsite	Amount Enclosed
Family	$150	$175
Individual	$100	$125
1-Day Attendance Please Indicate Day	$75	$75
	Total - Part 1

* After August 1, please phone in information and bring the completed registration form to the conference.

Part II: CANDLELIGHTERS SPONSORED SPECIAL EVENTS

Name	Pre-Conference Workshop (support Group Facilitator) Thurs 17 Aug. $10 per person	Saturday Banquet & Gala $35 Adult each $35 Child each	Babysitting Age of Infant(s) (0-4 yrs)	Child/Teen BBQ &Movie $10 per person	Amount Enclosed



Total - Part 2

Part III: TOTAL FEES AND PAYMENT METHOD

Total Registration Fee (Part I)	Registration must be accompanied by payment. Please make cheques or money orders payable to Candlelighters Conference. Card: Visa MasterCard
Total Special Events Fee (Part II)
Total Payment enclosed
	Card Number:	Expiry Date:
	Cardholder:
	Signature:

Please return your registration form and fees to:
Childhood Cancer and the Family
55 Eglinton Avenue East, Suite 401,
Toronto, Ontario, Canada, M4P 1G8
Phone: (416) 489-6440 Toll-Free: 1-800-363-1062
Fax: (416) 489-9812 (Fax only payment made by credit card)

For child/teen registration click here.

Si vous voulez ces formulaires en francais, appelez notre bureau au 1-800-363-1062