2012 MADD Canada’s National Conference for Victims of Impaired Driving
REGISTRATION FORM
April 27-29, 2012
The BMO Financial Group, Institute for Learning (IFL)
3550 Pharmacy Avenue, Scarborough, ON M1W 3Z3
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Accommodation: The BMO Financial Group, Institute for Learning (IFL) is fully accessible and offers high quality services. All accommodations at the IFL include “hotel amenities” such as hair dryers, irons and ironing boards in the rooms. The IFL is smoke-free with designated smoking areas outside.
The BMO Financial Group, Institute for Learning has double occupancy rooms, but only one queen-sized bed is provided. Delegates who choose to share a room but require more than one bed, will booked at The Holiday Inn nearby and shuttled to the IFL. The Holiday Inn is also a smoke-free environment with designated smoking areas outside.
Sponsoring: This year, MADD Canada will sponsor selected victims from across Canada to attend the National Conference for Victims of Impaired Driving. To find out if you are eligible for this sponsorship, please contact your Chapter Victim Services Volunteer or Gloria Appleby, .
If you are being sponsored by a Chapter, the local Chapter Board of Directors’ pre-approval is required before submitting this Registration Form.
If you do not have sponsorship, you will be responsible for covering the full cost of the weekend.
Please use a separate form for each delegate.
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Delegate's Name: ______
(please print clearly)
Address: ______
______
Chapter/Community Leader: ______
Telephone: Home ( ) ______Work ( ) ______
E-mail for confirmation & e-ticket (personal or Chapter) ______
*Airline tickets and confirmation of registration are sent via email, therefore it is very important that you provide an email address.
Would you like to include your email address in the Weekend program, to share with other delegates?
YesNo
Do you give permission for your photograph to be taken during the sessions and used in event-related reports or publicity?
YesNo
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Please return completed registration form
(page 1 and 2) and victim tributes (page 3) to:
Ardene Vicioso, MADD Canada,
2010 Winston Park Drive, Suite 500,
Oakville, Ontario L6H 5R7
Phone: 1-800-665-6233 or (905) 829-8805 ext. 227 Fax: (905) 829-8860 or email:
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TRANSPORTATION:
I will be driving from ______and arriving Thursday Friday Saturday morning
I will be flying from (airport) ______ Thursday Friday
I will be taking the train from ______ Thursday Friday
I will be requiring accommodation on Thursday, April 26th. Invoice the cost ($335) to me the Chapter (this must be pre-approved by the Chapter.)
OR
I will be attending the Candlelight Vigil Service Saturday ONLY (ie. No meals or accommodations required). The Vigil Ceremony will be held at The BMO Financial Group, Institute for Learning (IFL), in the Presentation Hall, 3550 Pharmacy Avenue, Scarborough, ON M1W 3Z3 on Saturday, April 28, 2012 at 7:30 pm – 9:00 pm. This service is open to the public and is free of charge to attend.
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Flight arrangements will be made through New Wave Travel. Once your registration has been confirmed by the National Office, you will be emailed the telephone number and contact person at New Wave Travel to book your flight. Delegates who fly will arrive Friday, April 27th and leave Sunday, April 29th close to 3:00 p.m. All plane tickets are non-transferable and non-refundable. Once flight arrangements have been confirmed, Chapters will be responsible for any additional costs.
Cost of cancellations will be the responsibility of the Chapter, or the delegate, if not sponsored by a Chapter. Flight and Train e-tickets will be sent to you by email.
**If flying, use the Airport Limousine coupon when arriving at Toronto’s Pearson Airport. This coupon will be mailed to you at your home address as indicated on this form.
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SPECIAL NEEDS
I have the following special needs (mobility, accommodation, meals, etc.): ______
ACCOMMODATION:
The National Office will make hotel reservations at the IFL or The Holiday Inn. We will be booking you a room for two nights: Friday, April 27th and Saturday, April 28th, 2012.
If it is necessary to cancel your registration, and accommodation charges are incurred, you will be responsible for the charges.
Delegates sharing a room and requiring more than one bed will stay at The Holiday Inn.
Please check if staying at The Holiday Inn and who you will be rooming with ______
CONFERENCE REGISTRATION COSTS:
Friday, April 27 to Sunday, April 29, 2012 (with accommodation)$750.00 per person
Friday, April 27 to Sunday, April 29, 2012 (without accommodation)$400.00 per person
Saturday, April 28, 2012 (lunch and dinner included)$150.00 per person
Candlelight Vigil Service Only, Saturday evening, April 28, 2012 No Charge
Please note that MADD Canada provides all meals consumed at The BMO Financial Group, Institute for Learning (IFL) only,
and will not cover any meal expenses incurred while traveling to, or home from the National Victims’ Weekend.
Our Mission: To stop impaired driving and to support victims of this violent crime.
Victim Tributes:
*Must be submitted no later than March 30, 2012 to be included on the Keepsake CD and the Vigil Ceremony.
Please complete the information below. If you are unable to attend and wish to include your tribute as an injured victim or your loved one’s tribute during the weekend, please indicate below:
Photo and short tribute at the Vigil Ceremony Photo and tribute in the Keepsake Book
In Tribute of:
Date of Birth (dd/mm/yyyy): / / Date of Death (dd/mm/yyyy): / /
And/or Date of Injury (dd/mm/yyyy): / /
Submitted by:
City: Province: Postal Code:
Photo Included Use photo on file at the National Office
(please describe photo if more than one has been submitted in the past)
MADD Canada will not automatically include all the tributes and photos from last year on either the Keepsake CD or for the Vigil Ceremony. Should you wish your loved ones’ photo or your photo and tribute from last year repeated please check:
Repeat last year’s submission or New submission: please see below
(Please note that submissions are only kept on file for one year, if you did not submit a tribute last year, you will need to submit a new one.)
Tribute to be read at the Vigil Ceremony (12 words or less – please note that we will edit all submissions that exceed 12 words).
Include this tribute on the Keepsake CD along with my submission below (up to 1 page in length).
You may wish to use this opportunity to describe your loved one(s).
If necessary, please attach another page. Tributes can be emailed in Word format, and photos in jpg. format to .
Each year for the National Conference for Victims of Impaired Driving, MADD Canada updates a portable Victims’ Memorial Wall where pictures of those killed or injured in an impaired driving related crash are displayed. Please indicate with an “X” here if you DO NOT wish your or your loved one’s picture(s) to be placed on this wall:
Registration deadline: March 16, 2012
Victim Tribute deadline: March 30, 2012
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