2nd Annual National First Nations eHealth Conference &

Assiniboia Downs, WINNIPEG MANITOBA

Please complete information below -­‐ Please note that the name and title you give here will be
printed on your badge and the participants’ list.

1. Participants information

Last name:

Title: £ Prof. £ Dr. £ other: £ Mr. £ Ms. £ Mrs.

First name:

Organization:

Address:

Postal/Zip code: City:

Country:

Telephone:

Fax: E--‐mail:

First Nation Member Community:

*Please include a copy of your valid ID.

2. Registration Fee

Registration fees include tea/coffee, lunch, and registration materials during the event.

All participants must complete a separate registration form. This conference is free of charge for
Elders and First Nations of Manitoba Health Organizations. Other non-First Nations and out of Province
First Nations are required to pay a nominal fee for adults and students.
REGISTRATION: SELECTION
DATE: PRICE: (X)
Conference Workshops Feb 5, 2018 $50

ICT Conference Feb 6, 2018 $100

ICT Conference Feb 7, 2018 $100

Health Information Management Feb 8, 2018 FREE

EXHIBITOR / TRADE SHOW BOOTH REGISTRATION: SELECTION

(X)
FIRST NATION MEMBER February 5-8, 2018 $200
CORPORATE February 5-8, 2018 $1000
SPECIAL EVENING ACTIVITIES: SELECTION
(X)
CULTURAL GALA EVENING
(1) TICKET February 7, 2018 $80
Table of 8 February 7, 2018 $600

YOUTH FUNDRAISING EVENING - TBD

(1) TICKET February 5, 2018 $20
YOUTH FUNDRAISING EVENING - TBD
(1) TICKET February 6, 2018 $20

3. PAYMENT OPTIONS:

BY CHEQUE:

Registration is not officially confirmed until payment by cheque is received, NO LATER THAN
JANUARY 31, 2018.
Please make cheques payable to:
First Nations Health & Social Secretariat of Manitoba
2nd Floor -­‐ 275 Portage Avenue
Winnipeg, MB R3B 2B3
* Mark to the attention of: Maggie Flett, FNHSSM Finance
* Please reference: National eHealth Conference/MNF ICT Summit Registration on cheque and
mailing envelope

BY CREDIT CARD:
(We accept Visa, Mastercard, American Express)
Registration is not officially confirmed until credit card payment is successfully processed.

CREDIT CARD TYPE:

CC #

EXPIRY DATE: 3 DIGIT SECURITY (CVV) CODE:

SIGNATURE: