Conference Registration

Contact

Registrant's Name(Required)

First Last

Address

Street Address City Province Postal Code

Email Address(Required)

Email Address Confirm Email Address

Mobile Phone(Required)

Emergency Contact

Name of Emergency Contact(Required)

First Last

Phone Number of Emergency Contact

BPW Club Information

Club Name(Required)

Your Role At Conference(Required)

Event Information

Dinner Selection(Required)

Please list any allergies

Payment(Required)

Please select the way you intend to pay.

$175.00 E-transfer: [email protected] Password: 2025BPWOAGM

$185.00 Credit Card: ($10 administration fee applies): I agree to complete this form promptly and contact [email protected], to make arrangements to pay my registration fee. Credit card number, expiry date and CCV No (3 digits on the back of the card), postal code

Signature

Date

Conference Registration

Contact

Emergency Contact

BPW Club Information

Event Information

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