First name Last name
Position/Title Department Organization/Institution
Telephone Fax Email
May we include your contact information on a participant list to which related announcements may be mailed? Yes No
SECTION TWO The Registration Fee includes the 1 day forum, refreshment breaks and lunch.
General registration $20.00
Payment can be made by cash or by cheque. Cheques should be made out to the Social Planning Council of Winnipeg. Please do not send cash by mail.
Please return the completed registration form along with payment to: Social Planning Council of Winnipeg/Co-operative Opportunities 412 McDermot Avenue Winnipeg, Manitoba R3A 0A9 204.942.3221 (fax) 204.943.2561 (t) email@example.com (e) www.spcw.mb.ca (web) SECTION THREE To help us provide you with better service, please check the appropriate boxes:
I will bring material for sharing with participants – videos, films, displays, printed materials
I have special dietary needs as follows:
I need special assistance to fully participate in the conference, as follows: