Personal Information

CONTACT AND PERSONAL INFORMATION

Please complete the following and submit by Thursday, March 31st, 2022. While entering data, please do not use the ENTER or RETURN keys to avoid sending the form before you are finished. Please use the TAB key to proceed from field to field.

Legal Name*

Please write your legal name to help us book your flights and hotel reservations properly.

First Name

Last Name

Your Study Group (Region you will be visiting during the conference)*

Email Address*

Dietary Restrictions/Preferences

Medical Requirements / Information

Medical requirements or conditions you feel the Conference Secretariat should know about (for example: disabilities, severe allergies, asthma, epilepsy, special medicine requirements, etc...)

EMERGENCY CONTACT

Name*

First Name

Last Name

Relationship to the participant*

(i.e. Spouse, Brother, Friend, etc...)

Email address*

Telephone*

JACKET SIZE

Please refer to this chart to find your appropriate jacket size

Jacket Type*

Male

Female

ANY OTHER SPECIAL REQUIREMENTS OR COMMENTS

Please share any other information that you feel the Conference should know in order to maximize your experience.

IMPORTANT - Please contact us at info@leadershipcanada.ca if you do not receive an email confirmation within the next 5 minutes. Thank you

This field should be left blank