NLMA Forms
Safe Harbour Registration Form

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Instructions Use this form to register for Safe Harbour.

Registrant (NLMA Members ONLY)

Name

NLMA Number

Badge Name

Badge Title

Diet/Allergies

Registration

Registrant registration includes all workshops, nutrition breaks, lunches, and dinner for one (1) adult.

Registrant (Non-NLMA Members ONLY)

Name

Organization

Job Title

E-mail

Badge Name

Badge Title

Diet/Allergies

Registration

Registrant registration includes all workshops, nutrition breaks, lunches, and dinner for one (1) adult.

Guest 1 (Optional)

Badge Name

Diet/Allergies

Registration
(Check all that apply)

Workshops (Adults ONLY; includes lunch and nutrition break)
Beat the Clock (October 20) - $100.00
The Situation Room (October 20) - $100.00
Buried in Paper and Other To-Dos? (October 21) - $100.00

Lunches (Adults ONLY; already included if registering for a same-day workshop above)
Adult Set Menu (October 20) - $34.58
Adult Set Menu (October 21) - $34.58

Dinner (Adults and children; two sittings, young children encouraged to attend the earlier)
Adult Set Menu (October 20) - $87.78
Child Under 16 Set Menu (October 20) - $43.89

Guest 2 (Optional)

Badge Name

Diet/Allergies

Registration
(Check all that apply)

Workshops (Adults ONLY; includes lunch and nutrition break)
Beat the Clock (October 20) - $100.00
The Situation Room (October 20) - $100.00
Buried in Paper and Other To-Dos? (October 21) - $100.00

Lunches (Adults ONLY; already included if registering for a same-day workshop above)
Adult Set Menu (October 20) - $34.58
Adult Set Menu (October 21) - $34.58

Dinner (Adults and children; two sittings, young children encouraged to attend the earlier)
Adult Set Menu (October 20) - $87.78
Child Under 16 Set Menu (October 20) - $43.89

Guest 3 (Optional)

Badge Name

Diet/Allergies

Registration
(Check all that apply)

Workshops (Adults ONLY; includes lunch and nutrition break)
Beat the Clock (October 20) - $100.00
The Situation Room (October 20) - $100.00
Buried in Paper and Other To-Dos? (October 21) - $100.00

Lunches (Adults ONLY; already included if registering for a same-day workshop above)
Adult Set Menu (October 20) - $34.58
Adult Set Menu (October 21) - $34.58

Dinner (Adults and children; two sittings, young children encouraged to attend the earlier)
Adult Set Menu (October 20) - $87.78
Child Under 16 Set Menu (October 20) - $43.89

Notes

Requests/Questions


(*required)

Policies
Deadline Registration closes 5 pm, Friday, October 5.
NLMA Cancellation
The NLMA reserves the right to cancel this event due to insufficient registration or circumstances beyond our control; registrants will be notified and provided a full refund. The NLMA is not responsible for any non-refundable costs, including, but not limited to, airline or accommodation costs.
Registrant Cancellation Cancellations received by 5 pm, October 5, 2018 will receive a full refund of the registration fee, less a $50 cancellation fee. Cancellations received after 5 pm, October 5, 2018 will be charged a $250 cancellation fee.


Assistance For assistance, please contact Suzan Izquierdo at (709) 726-7424 (318), (800) 563-2003 (318) or sizquierdo@nlma.nl.ca.

Newfoundland and Labrador Medical Association
NLMA House, 164 MacDonald Dr., St. John's, NL, Canada, A1A 4B3
Telephone (709) 726-7424 | Toll Free (800) 563-2003 | Fax (709) 726-7525
E-mail nlma@nlma.nl.ca | Web www.nlma.nl.ca