Registration: 2024 CAN-ACT Meeting Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.SalutationName *FirstLastSuffixPreferred Name for ID Tag (*Leave this field empty if you would like your name to appear as entered above)Email *AttendanceAttendee Type *Clinician/ResearcherPatient PartnerOtherInstitution *City & Province of Residence *Will you be attending the Dinner Reception? (*Reception will be held offsite at 6:00 PM on Friday, May 31st. Transportation will be arranged.) *YesNoAccomodationsDo you require a guest room at the hotel? *YesNoPlease note any allergies or dietary restrictions: (*Will be provided to the caterers for meals at the Hotel and the Dinner Reception)Which nights will you stay at the hotel? (Check all that apply) *Thursday, May 30, 2024Friday, May 31, 2024Personal Address (for hotel booking) *Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountrySpecial Requests for Hotel (optional)TravelHow would you like travel arranged? *Have travel booked for youBook travel yourself & be reimbursedI do not need travel arrangements madeIf you are booking your own travel: You will receive an email confirming your choice. Reimbursement for an economy class ticket will be provided. Any cost in addition to an economy class ticket will be the responsibility of the traveler. Please save your travel invoice(s) and email to Lindsay Parsons at lindsay.parsons@loeysdietzcanada.org. How will you be travelling? *TrainPlaneFull Name (As it appears on your ID) *Birth Date *Cell Phone Number (for airline notifications) *Departure: Preferred Airport *Departure: Date *Departure: Preferred Time of Day (*Indicate the time you would like to leave your departure airport) *Return: Date *Return: Preferred Time of Day (*Indicate the time you would like to fly out of Montreal) *Baggage Requirements *Carry-On Bag & Personal Item onlyChecked Bag RequiredChecked Bag Information: Please indicate how many bags you need to check and any other special requirements *Full Name (As it appears on your ID) *Birth Date *Cell Phone Number (For train alert system) *Departure: Preferred Station *Departure: Date *Departure: Preferred Time of Day (*Indicate the time you would like to leave your departure station) *Return: Date *Return: Preferred Time of Day (*Indicate the time you prefer your train to leave Montreal) *Please click "Submit" to complete your registration. Submit
