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CONTACT INFORMATION First name: Title Title - None -MissMsMrMrsDrOther… Enter other… First name: Last name: Address Address Address 2 City/Town State/Province ZIP/Postal Code Country - None -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSarkSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkmenistanTurks & Caicos IslandsTuvaluTürkiyeU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Primary phone number Alternative phone number (optional) Email ADDITIONAL INFORMATION: I am involved with: Long Term Care Home Acute Care Facility Community Rehabilitation Centre CHT/FHT Other Please enter details My profession is: Educator / Health Promoter Administrator / Manager Social Worker / Discharge Planner Physician Nurse PSW Therapist Medical Trainee / Resident Research Pharmacist Student Other Please enter details: SELECT WORKSHOPS: LEGEND - WORKSHOP SUITED FOR: (A) - Allied Health, (N) - Nurses, PSWs, (P) - Physicians, Pharmacists 10:00am – 11:05 Morning Concurrent Workshop (choose 1): - Select -1. The Power of Storytelling: Creating Indigenous Cultural Safety Together (Elder Roberta Price) (A,N,P)2. New Advances in the Biological Diagnosis of Dementia (Jaspreet Bhangu) (A,M,P)3. A Neuron's Approach to the Evaluation of Falls (David F. Tang-Wai, MD) (A,N,P)4. Medical Aid in Dying (MAiD)—Where Did We Come From, Where We Are At, And Where Are We Going (A,N,P)5. Osteoporosis Guidelines (Jenny Thain, MD) (A,N,P)6. My Vagina has Fallen and Can't get up-Pelvic Organ Prolapse and Incontinence Considerations in the Aging Woman (Yvonne Leong, MD) (A,N,P) 11:30am – 12:35pm Morning Concurrent Workshop (choose 1): - Select -7. The Power of Storytelling: Creating Indigenous Cultural Safety Together (Elder Roberta Price) (A,N,P)8. A Neuron's Approach to the Evaluation of Falls (David F. Tang-Wai, MD) (A,N,P)9. Medical Aid in Dying (MAiD)—Where Did We Come From, Where We Are At, And Where Are We Going (A,N,P) (George Kim, MD)10. Staying Dry and Comfortable: Tips and Tricks to Improve Quality of Life for Aging Men Facing Incontinence (Jeffrey Campbell, MD) (A,N,P)11. Social Isolation and Loneliness (SIL)-The Hidden Cost and Things that Work to Improve It (Jacques S. Lee, MD) (A,N,P)12. Developing an Approach to Complex Cases in Older Adults (Sheri-Lynn Kane, MD) (A,N,P) 2:45am – 3:50pm Afternoon Concurrent Workshop (choose 1): - Select -13. Drug Interactions for Normal People (Peter Lin, MD) (A,N,P)14. Osteoporosis and Exercise for Older Adults (Christina Ziebart, PT) (A,N,P)DO NOT SELECT/No longer available:15. Developing an Approach to Complex Cases in Older Adults (Sheri-Lynn Kane, MD) (A,N,P)16. Meeting Dementia Education Needs for Allied Health Professionals (Susan Hunter, PT) (A,N,P)17. Social Isolation and Loneliness (SIL)- The Hidden Cost and Things that Work to Improve it (Jacques S. Lee, MD) (A,N,P)DO NOT SELECT/No longer available:18. A Paradigm Shift Towards Ageism-Free & Human Rights Based Culture of Care (Kiran Rabheru, MD) (A,N,P) LEGEND - WORKSHOP SUITED FOR: (A) - Allied Health, (N) - Nurses, PSWs, (P) - Physicians, Pharmacists PAYMENT Type of registration: General registration - $175.00 Student/Volunteer - $85.00 Method of payment: PayPal/Credit Card Cheque PO (LHSC and St. Joseph's employees only) Paypal/Credit Card You will be directed to the PayPal page to complete payment after you enter submit. A paypal account is not required, you will be given an option to pay with credit card without signing up for Paypal. For Purchase Orders, please include email address of supervisor: Mailing address for cheques: Cheques should be made out to St. Joseph’s Health Care London – GRD Send to: Parkwood Institute, Main Building PO Box 5777, STN B London, ON N6A 4V2 ATTN: Amy Lane, Division of Geriatric Medicine, Room A2-129 This personal information is being collected under the authority of the Public Hospitals Act R.S.O. 1990, CHAPTER P.40 for the purpose of contacting the sender in response to an inquiry. If you have questions about the collection of this information, please contact Privacy and Freedom of Information, St. Joseph's Health Care London, 268 Grosvenor Street, London, ON,519-646-6100 ext. 65591.
