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Level 1 Multidisciplinary Palliative Care Education
Based on Fundamentals
REGISTRATION FORM
Registration will be confirmed via email or by phone
Location:
The Royale Retirement Residence
2485 Princess St.
Kingston ON, K7M3G1
Dates:
Jan 14, 21, 28 and Feb 4, 11,18 2015
Registration Deadline: Jan 5 2015
or when class is full
Maximum Class Size:
20 (register as soon as possible)
Minimum Class Size:
15 participants are required
Name:
Workplace:
Position:
Home Phone:
Work Phone:
Fax:
Email:
Supervisors Name:
Phone:
Have you had any palliative care training before?
100% attendance is greatly encouraged.
80% attendance (5 days of 6) is a must to obtain Certificate of Completion
There is no cost to the individual for this course.
Return this form to :
Facilitator:
Penny Sperou, Support Assistant
South East CCAC 52 Abbott St. North, Unit#1
Smiths Falls ON K7A 1W3
Phone: 613-283-7254 ex.5260 OR 1-888-871-8868
Fax: 613-283-0308 Email: [email protected]
Carol Northcott Phone:613-283-7254 ex 5288, [email protected]