Advanced Gerontological Education Inc. (AGE)

Introduction

Step 1: Contact Information

All fields are required unless indicated otherwise.

First Name

Last Name

Discipline/Title

Promo Code

Issued on pre-arranged group registrations only. (Optional)

Please use the fields below to briefly address the following prerequisite items (100 word max).

Experience in dementia care, geriatric care or a related field:

Experience in mentoring/coaching/precepting teaching:

Relevant job role and ongoing relationship with recipients of GPA Educations Sessions:

Please provide a comment indicating your employer's support in attending this workshop:

What experience do you have facilitating education/training/meetings using Zoom or other platforms (Google Meet, Microsoft Teams, etc.)?

Please confirm that you have completed GPA eLearning or will complete prior to the workshop?

Agree

Language preference for workshop materials:

English

French

If you are attending an in-person workshop, materials will be provided at the workshop.
Materials will be couriered to you ONLY IF you are attending a virtual workshop. Please enter ship to address: Workshop Materials Shipping Address Line 1

Workshop Materials Shipping Address Line 2

City

Province

Postal Code

Organization Province

Region

Organization

Please select your organization from the drop-down menu above. If your organization is not listed, please select 'Other' and specify the details of your organization.

New Organization

Region

Organization Name

Address 1

Address 2

Unit

Country

City

Postal Code

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LHIN

(if applicable)

Phone

( ) - Ext. Home phone or cell (require for shipping confirmation)

Alternative Phone

( ) - Ext.

Email Address

Unique and valid user email address is required for each registration. This will be used for primary contact and your GPA Certified Coach Login.

Alternative Email Address

Food Allergies (only if attending an in-person workshop) *

NOTE: we do our best to accommodate food allergies and sensitivities however we cannot always guarantee due to the ability of the catering vendor available. (Optional)

Introduction

Workshop

Date

Location

Address

Cost

Details

Step 1: Contact Information

New Organization