Canadian Institute of Public Health Inspectors

CANADIAN INSTITUTE OF PUBLIC HEALTH INSPECTORS CONTINUING EDUCATION WEBINAR SERIES FALL 2016 DELEGATE REGISTRATION FORM Please complete this form if you are NOT an Environmental Public Health Professional employed by First Nations Health, Fraser Health, Interior Health, Northern Health, Vancouver Coastal Health, or Vancouver Island Health Authorities. Name: Phone: Employer: Fax: Address: Email: Select the following session(s) that you are interested in attending:  Enteric Outbreak Toolkit  FRESH: Farmed and Raised September 22, 2016 – Eating for Student Health 9:00 – 10:00 (PDT) – FREE! Christine Gardhouse – PHAC November 09, 2016  Earthquake Hazard and 9:00 – 10:00 (PST) Public Health Inspectors in Kristen Houwers, Helen the BC Emergency Wang, Matthew Loo, Kelson Management System Mah – BCIT November 30, 2016  Understanding Professional 9:00 – 10:00 (PST) Development Hours Entry – Kathryn Forge – BC MoH FREE! John Lavery – HEMBC November 22, 2016 9:00 – 10:00 (PST) Keir Cordner – CoPE/FNHA

Registration Fees:  Environmental Public Health Professionals $35 for all four sessions  Students / Retirees $15 for all four sessions  Life Members Complimentary Method of Payment:  Cheque / Money Order (Payable to CIPHI BC Branch)  Credit Card: NAME: TOTAL AMOUNT: CARD NUMBER: SIGNATURE: EXPIRATION DATE:

Please submit completed registration form and payment to [email protected] OFFICIAL USE ONLY Date of Payment Received (mm/dd/yy): Confirmed Payment: