Candlelighters Childhood Cancer Foundation Canada

Registration Form

CHILDHOOD CANCER AND THE FAMILY: TOGETHER WE CARE
REGISTRATION FORM

Please print and complete the following information:

* These items will appear on your conference name badge

PART I: REGISTRATION CATEGORIES AND FEES

* After July 20, 1998, registration should be held rather than mailed and processed on site.

PART II: CANDLELIGHTERS SPONSORED SPECIAL EVENTS

PART III: CONFERENCE T-SHIRTS

100% pre-shrunk cotton T-shirts in white with the 1998 Together We Care conference logo in green and yellow will be available for purchase at the conference in limited quantities. We recommend pre-purchase to avoid disappointment.

PART IV: MEDICAL QUESTIONNAIRE

To assist Children's Hospital in planning for possible care of your child during your conference stay, please complete the following information:

1. Is your child currently receiving treatment for cancer?                                          | Yes | No |

2. Will your child need to receive ongoing treatment at the Children's
    Hospital during the conference?                                                                                | Yes | No |

3. Please indicate the treatment your child will require:
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At the time of the conference, your child's physician should provide a letter outlining your child's medical status and care to help physicians at either Montreal Children's Hospital or Hopital Ste. Justine, should their involvement be necessary.

4. To facilitate your child's involvement in the children's program,
    please indicate if one-on-one care is necessary:                                                     | Yes | No |

5. In an effort to meet your family's need please indicate:

Wheelchair access is necessary:                                                                      | Yes | No |

Dietary Restrictions:                                                                                           | Yes | No |

Please explain: _______________________________________________________________________

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PART V: SESSION CHOICES

As session rooms are all of comparable size and we recognize that conference participants often change their selections once the conference begins, you are not asked to indicate your workshop/presentation preferences at this time. Seating will be on "first come" basis.

PART VI: TOTAL FEES AND PAYMENT METHOD

Registration must be accompanied by payment. Please made cheques or money order payable to Candlelighters Conference.

We are pleased to accept either VISA or MasterCard as payment methods.

Card (Circle one):                            VISA                                        MasterCard

Card Number: _____________________________________________Expiry Date: ___________

Cardholder: ___________________________________________________________________

Signature: ____________________________________________________________________

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