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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 MarinoSaudi 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 CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.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: 10:00am – 11:05 Morning Concurrent Workshop (choose 1): - Select -1. Managing Conflict Effectively (Dr. Mamta Gautam)2. Cannabis Use in the Older Adult (Dr. Amanjot Sidhu)3. Cognitive Testing-Localization and Interpretation (David F. Tang-Wai)4. Knowing What You Don't Know; Reducing Bias Through Knowledge (Nancy Buchanan, Krista Doxtator)5. Osteoporosis in LTC (Dr. Jenny Thain)6. Exploring the Impact of Sociopolitical Grief(SPG) on Health & Social Care Workers (Darcy Harris) 11:30am – 12:35pm Morning Concurrent Workshop (choose 1): - Select -7. Managing Conflict Effectively (Dr. Mamta Gautam)8. Cannabis Use in the Older Adults-Current Evidence and How it is Being Used in the "Real World" (Dr. Amanjot Sidhu)9. Cognitive Testing-Localization and Interpretation (David F. Tang-Wai)10. Enhancing the Palliative Approach to Care by Embracing the Recovery Philosophy (Franzis Henke)11. Update on Canadian Guidelines on the Prevention, Assessment and Treatment of Depression Among Older Adults (David K. Conn)12. Immunization and Older Adults (Dr. Alexander Summers) 2:45am – 3:50pm Afternoon Concurrent Workshop (choose 1): - Select -13. Baby Boomers and Aging (Dr. Peter Lin)14. Gait Aids and Falls in Older Adults: Optimizing Safety (Susan Hunter)15. Creating an Evidence-Based Culture in LTC by Implementing RNAO Best Practice Guidelines (Terri Benwell)16. Enhancing the Palliative Approach to Care by Embracing the Recovery Philosophy (Franzis Henke)17. Update on Canadian Guidelines on the Prevention, Assessment and Treatment of Depression Among Older Adults (David K. Conn)18. Immunization and Older Adults (Alexander Summers) PAYMENT Type of registration: General registration - $160.00 Student/Volunteer - $75.00 Method of payment: PayPal Cheque PO (LHSC and St. Joseph's employees only) Paypal option 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: Division of Geriatric Medicine Parkwood Institute, Main Building PO Box 5777, STN B London, ON N6A 4V2 Attn: Brenda Honsinger, 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.
