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REGISTRATION
Medi-Pro Educational Services Inc..
OSPE Intensive Program (Edmonton/Calgary) Alberta
July/August 2015
A. PERSONAL INFORMATION:
*Please PRINT CLEARLY in INK:
NAME: ____________________,______________________
Last
First
ADDRESS: _______________________________________
CITY: ___________________________________________
PROVINCE: ______________________________________
POSTAL CODE: __________________________________
COUNTRY: _______________________________________
EMAIL: _______________________@_________________
CONFIRM EMAIL: _______________________@_________________
PHONE NUMBER: _____-_____-______/______-______-_______
Home
Cell
B. LOCATION CHOICE:
*Please select your choice of Program below:
EDMONTON @ Robertson College, 300 - 10115 100A Street, Edmonton:
July 24 – 26, 2015: _____
CALGARY @ Robertson College, 200 - 417 14th Street NW, Calgary:
August 07 – 09, 2015: _____
Please Note: Programs are designed for a maximum of 30 students and a minimum of 25.
If any one Program fails to meet a minimum of 25 students four weeks prior to its start date, we reserve
the right to cancel that particular Program.
However, registrants do have the option at any time of transferring to their program of second-choice
should they choose to do so, but only if there is space available in that particular Program.
C. PAYMENT OPTIONS:
TOTAL COST: CAD $498.75 ($475.00 + GST of $23.75)
Payment may be made by Interac e-Transfer (preferred) or by cheque/bank draft/ money order.
1) I confirm: one (1) Interac e-Transfer in the amount of CAD$___________,
to be made on (date): ____________________________
Initials: _______________
2) I enclose: one (1) cheque/bank draft/ money order, payable to Medi-Pro Educational Services Inc.. in
the amount of CAD$___________, (date): ______________________
**NSF cheques will be subject to a re-deposit charge of $25.00
Initials:_______________
PLEASE NOTE THE FOLLOWING:
*In fairness to all registrants, registrations are not confirmed until your payment has cleared. Confirmation
of receipt of funds and registration will be sent to you by e-mail.
**Post-dated cheques/Interac e-Transfers (up to June 30, 2015) ARE accepted, however, registration is always
done on a fully-paid, first-come, first-served basis.
Therefore, regretfully, there can be NO guarantee that seats will be remaining in your Program(s) of choice at
the time of your post-date.
***PLEASE READ the Cancellations policy carefully! Thank you!
D. TERMS AND CONDITIONS OF REGISTRATION:
Cancellations:
Cancellation requests received 15 – 30 days prior to the first day of the scheduled Objective Structured
Performance Examination (OSPE) Intensive Program are subject to a cancellation charge of $200.00 .
Cancellation requests received 14 days or less prior to the first day of the scheduled Objective Structured
Performance Examination (OSPE) Intensive Program are subject to 100% of program costs payable as
liquidated damages to Medi-Pro Educational Services Inc..
Initials: _______________
Absences:
Any and all absences from any part of this program are solely the responsibility of the client: Medi-Pro
Educational Services Inc. is not responsible for reimbursement of either time or funds for client absence.
Initials: ______________
Confidentiality:
As a client of Medi-Pro Educational Services Inc., you agree not to take photographs, audio or video recordings
or use any other means of duplication of material and content used throughout the program. All materials
presented to you, including all practice cases, course curriculum, the cases and topics for the mock OSPE itself,
and also including the practice material provided to you by guest speakers and/or Medi-Pro employees, are
strictly the property of Medi-Pro Educational Services Inc..
You agree therefore to keep all of the aforementioned as confidential.
Any breach of this confidentiality agreement will result in immediate termination of your participation in the
program – with 100% of program costs payable as liquidated damages to Medi-Pro Educational Services Inc. –
and may also result in legal action on the part of Medi-Pro Educational Services Inc..
Initials: ______________
Furthermore, as a client of Medi-Pro Educational Services Inc. you also agree not to participate, directly or
indirectly, in the creation of any company that would be in direct competition to Medi-Pro Educational Services
Inc. within the Province of Alberta.
Initals: _______________
Termination from the Program:
In addition to termination from the program for breach of confidentiality, termination from the program may
also result from disruptive or fraudulent activity while enrolled in the program. Any such activity will also result
in the immediate termination of your participation in the program with 100% of program costs payable as
liquidated damages to Medi-Pro Educational Services Inc..
Initials: ______________
E. AGREEMENT
I, ____________________________, (full name) agree to the terms and conditions as specified and as initialled
by me above.
Name: _______________,_______________
First
Last
Signature: ______________________________
Date: __________________________________
**In order for the program to serve you better, please inform us of the following (if applicable):
Initial Pharmacy Technician program taken ___________________________________ (location)
Year of graduation __________________________________ (date)
Evaluating Examination passed? Yes/No
MCQ passed? Yes/No
If yes, when? Year _____
If yes, when? Year _____
OSPE attempted? Yes/No If yes, the next attempt will be your second/ third/ fourth?
F. PAYMENT DETAILS:
*If payment is to be made by Interac e-Transfer (preferred):
Please send via FAX OR EMAIL ATTACHMENT:
1. The completed REGISTRATION form including:
2. The initialled and signed TERMS AND CONDITIONS to:
Fax: 780-963-7160 OR Email: [email protected]
Please send:
3. Your INTERAC E-TRANSFER in the amount of CAD: ________,
to [email protected]
**Please use “What is this payment for?” as the Security Question, and please enter
“Registration” for the Required Answer. Thank you!
**If payment is to be made by cheque/money order/bank draft:
Please send via MAIL - Priority or XpressPost preferred for tracking purposes:
1. The completed REGISTRATION form including:
2. The initialled and signed TERMS AND CONDITIONS to:
MEDI-PRO EDUCATIONAL SERVICES INC..
PO Box 2762
Stony Plain,
Alberta, T7Z 1Y3
Canada
Please include:
3. Your CHEQUE/MONEY ORDER/BANK DRAFT in the amount of CAD$: ________, payable to
Medi-Pro Educational Services Inc.,
For further information, please e-mail to [email protected], or call 780-970-1896. We will be happy to
chat with you and to answer any questions you may have!
Thank you for choosing Medi-Pro!