Registration Form
Mail in this registration form or register by calling 519-685-8742 (Monday to Friday 8:30 am - 4:30 pm EST)
REGISTRATION DEADLINE: September 7, 2007
For more information, please call: (519) 685-8742
Attendee Name: ______________________________________________________________________________________
Address:____________________________________________________________________________________________
City: _______________________________________________________________________________________________
Province: ______________________________________
Postal Code: _______________________________________
Telephone: _____-__________________________ E-mail*: __________________________________________________
Second Attendee (Full Name): __________________________________________________________________________
BREAK OUT SESSIONS: (choose one per attendee)
Dental Health and Osteonecrosis of the Jaw
Free Light Chain Assay
- Dr. G. Soskin, London Health Sciences Centre
- Dr. Mélanie Giroux, The Binding Site
Amyloidosis
Clinical Trials: What You Need to Know
- Dr. M. Gertz, Mayo Clinic
- Dr. D. Reece, Princess Margaret Hospital
Surgical Management of Myeloma Lesions of the Spine
Customizing Treatments for Myeloma Patients
- Dr. M. H. Ford, Sunnybrook Health Centre
- Dr. K. Stewart, Mayo Clinic
SEMINAR COST:
Early Bird (registrations must be received by July 12, 2007)
$30.00 (one person)
$50.00 (two people)
Registrations received AFTER July 12, 2007
$40.00 (one person)
$70.00 (two people)
(Fees include refreshments, lunch, conference materials, and taxes.)
METHOD OF PAYMENT:
Cash
Cheque
VISA
MasterCard
CREDIT CARD:
Expiry Date:
___ / ___ / ___ / ___
Card Number:
___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___
Card Holder's Name: _______________________________________________________________________________
Card Holder's Signature: ____________________________________________________________________________
Please mail completed registration form and make cheque payable to:
EDUCATION, LONDON REGIONAL CANCER PROGRAM
London Regional Cancer Program, London Health Sciences Centre,
790 Commissioners Road East, London Ontario N6A 4L6
*Registration will be confirmed by email. Hotel information, maps and directions will be included with the confirmation.
If you do not have email, your registration will be confirmed by telephone.

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