Bridging Indigenous Knowledge with the Latest Information on Commercial Tobacco. Conference March 17-18, 2015 Registration Form First Name_ _______________________________ Last Name__________________________________ First Nation or Tribal Council Representing_ ________________________________________________ Work Title____________________________________________________________________________ Email Address______________________________ Mailing Address______________________________ Telephone_________________________________ Fax________________________________________ Dietary Requirements and/or Allergies_____________________________________________________ Check what pertains to you: q If you are the person receiving mileage, identify who you are carpooling with______________________________ . q For private accommodations @ $50 per night OR q Staying at Viscount Gort Hotel Please note that full attendance is mandatory to receive sponsorship. Travel will be reimbursed during the afternoon of the last day of your attendance (March 18 or March 19 depending if you are participating in training). If you require a travel advance, you must make this request at the local level as per administrative policy SERDC does not grant advances. q I will be participating in the March 19 training. AM training topic: Brief Intervention Tobacco Cessation facilitated by Marsha Simmons, SERDC Health. PM training topic: NOT – Not on Tobacco Youth Cessation Facilitator Training facilitated by George Koch, Manitoba Lung Association. Certificates provided to those with full attendance. Brief Intervention Tobacco Cessation Overview: This training is geared for those willing and able to assist individuals dependent on commercial tobacco products to quit their tobacco misuse. Participants will be trained on techniques including identifying a person’s readiness to quit commercial tobacco, how to deliver brief individual interventions, assist a person in creating a simple quit plan and information on where to refer people for more intensive services. NOT Not on Tobacco Cessation Overview: Training participants will be better prepared to help teens quit commercial tobacco. Ave. ba 5 1 Optional training date March 19, 2015 NOT will cover the following topics: understanding reasons for smoking, preparing to quit, nicotine addiction and withdrawal, accessing social support, coping with stress and preventing relapse. [email protected] motions.com Deadline to submit registrations is Friday, February 20, 2015. No late registrations will be accepted after this date. Registrations can be faxed to (204)934-0374 or via email [email protected] For more information please feel free to contact Marsha Simmons Southern Manitoba First Nations Commercial Tobacco Prevention Coordinator (204)956-7500 ext. 148 or [email protected] Please note that 4 spots per First Nation and 4 spots per Tribal Council will be fully sponsored to attend this includes: 2 mileages per First Nation or Tribal Council (carpool 2 people), meals, private accommodations or accommodations direct billed by this project at the Viscount Gort Hotel and incidentals all based on SERDC rates. We are kindly requesting that 1 spot be delegated to leadership for your First Nation such as a Health Portfolio Councillor and 3 spots for Health Programmers and/ or youth.