Forum Registration Forum Registration Personal InformationSalutationMr., Ms., etc.First Name * RequiredLast Name * RequiredEmail Address * Required Country * RequiredTitle * Requirede.g. job title or "not applicable"Organization * Requiredaffiliation or "not applicable"Which best describes your place of work? * RequiredUniversity (or other Academic Institute)Research/Knowledge Production OrganizationCommunity-Based Health CareHospitalCommunity-Based OrganizationNon-Governmental OrganizationService Provider OrganizationOther (Please specify below)Prefer not to answerIf you answered "Other" to "Place of work", please specify:Which of the following best describes your current role? * RequiredPlease select one.Academic (e.g. Located in an Academic Institution)ClinicianResearcherCommunity MemberEducatorService ProviderTrainee (e.g. MSc, PhD, Postdoc)Other (please specify below)Prefer not to answerIf you answered "Other" to "current role", please specify:I am a member of Realize * RequiredYesNoAttendance CertificateI would like to receive an Attendance Certificate Address Street Address * RequiredCity * RequiredProvince/Territory * RequiredPostal Code * RequiredRegistration Fee * RequiredIf you require assistance with the Registration fee, please contact Janet London at JLondon@HIVandRehab.caIndividual Realize Member - $75Individual Realize Associate - $100Individual Non-member - $125Organization Member first attendee / delegate - $75Organization Member additional attendees / delegates - $50Corporate (non-member) - $200 (a tax receipt will be issued for $100)Individual Member Price: $ 75.00 CAD Individual Associate Price: $ 100.00 CAD Individual Non-member Price: $ 125.00 CAD Member Organization First Price: $ 75.00 CAD Organization Extra Price: $ 50.00 CAD Corporate Price: $ 200.00 CAD I wish to make an additional donation to Realize in the following amount Total $ 0.00 CAD Payment Method * RequiredI will mail a cheque payable to "Realize"PayPalI will pay in-person at the eventAttendance Details French, English and sign interpretation will be made available on an as-needed basis. The facility is wheelchair accessibleI would like to receive my delegate kit in English French Special Needs French/English interpretation ASL interpretation LSQ interpretation Braille editions of background documents Large Print editions of background documents Refrigeration Sharps disposal Food sensitivities (please specify below) Other (please specify below) Food SensitivitiesOther - please specifiy This iframe contains the logic required to handle Ajax powered Gravity Forms.