REGISTER: KnowledgeConnect Dialogue: Mobile Harm Reduction and the Stimulus Conference Date: Wednesday October 17th Time: 10 – 11 AM Pacific time Information collected on this application form is confidential and will be used solely for the purposes of determining attendance, evaluation purposes and for post-event follow up by the event sponsors. KnowledgeConnect: Learn OnlineName(Required) First Last Email(Required) Organization(Required)Role or job title(Required)Registrant Information (for Evaluation Purposes)We evaluate all our events to help us learn how best to meet the needs of participants. Please fill in your information below. We will ask you to complete a short evaluation after the event. Thank you. Which health region do you live or work in?(Required) Fraser Island Interior North Vancouver Coastal Provincial National (outside BC) Other (please add information below) If you indicated "Other" for health region, above, please add your information hereHow would you describe yourself? (check all that apply) Work/volunteer at a community-based organization Work for government institution (health authority, Ministry) Am a healthcare provider (nurse, doctor, social worker, etc.) Am an academic (researcher, student) Am a consultant Work for the private sector Other (please enter information below) If you indicated "Other" in description above, please add your information hereMedia Release AckowledgementIn participating in this webinar, I acknowledge that PAN records webinars and that my name, voice, and image may be recorded during this process. I give PAN the right and authority to use my name, voice, and image if applicable, for their purpose, both commercial and non-commercial. I give permission for my voice and name to be recorded.(Required) Yes No Receive PAN Weekly NewsThe PAN Weekly News provides community updates, learning events, research news and job postings. Would you like to subscribe? I would like to subscribe to the PAN Weekly News. Yes, add my name to subscriber list. Thank you! Once you complete this form, you will be taken to the Webinar section of our website. Δ
