Workshop Registration Form

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Registration fee is $40 and includes material and light lunch. Please make cheques payable to the "Central Western Ontario District Council" and mail to: 2790 Hergott Road, Box 374, St. Clements, ON N0B 2M0. Please note: there is a parking fee of $5 per vehicle payable upon arrival at the University.

First Name *

Please enter the first name of the participant

Last Name *

Please enter the last name of the participant

Email Address *

Please enter the email address of the participant.

Primary Contact Telephone Number *

Please provide a telephone number you are easily reached at.

CUPE Local Number *

The number assigned to your Local. ie: CUPE Local XXXX

Street Address #1 *

Please enter the street name and number of the participant

Street Address #2

Please enter any additional mailing address information of the participant (ie: suite #)

City *

Please enter the city where the participant lives.

Province *

Please enter the province of the participant

Postal Code *

Please enter the postal code of the participant

Workshop Registration *

Which workshop would you like to register for?

Health & Safety Learning Series

Required

Payment Confirmation *

Payment will be forwarded within 7 days of registration or space will be released

Payment will be forwarded according to registration requirements.

Required

Special Requests *

Please indicate if you have any allergies, dietary, access or mobility restrictions.

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