Conference Registration

Registrant's Name(Required)

First Last

Address

Street Address City Province Postal Code

Email Address(Required)

Email Address Confirm Email Address

Mobile Phone(Required)

Name of Emergency Contact(Required)

First Last

Phone Number of Emergency Contact

Club Name(Required)

Your Role At Conference(Required)

Dinner Selection(Required)

Please list any allergies

Event Price TBD

Price:

* Final Event Price TBD

Event Donation

I would like to give a donation to this event

Please provide donation amount

Total Based On Selections Above

Payment(Required)

Please select the way you intend to pay.

E-transfer: [email protected] Password: 2025BPWOAGM

Credit Card $TBD + $5 more for Mastercard, Visa and Amex

Signature

Date