Doctors Manitoba | Who's Who in the Zoo

First Name *

Last Name *

Email *

Phone Number *

I am a: *

Medical Student

Resident

MLPIMG or PRA

Practicing Physician (1^st 5 years in Practice in Manitoba)

Practicing Physician (5 plus years in Practice)

Retired Physician

If you selelcted Medical Student, please indicate which year you are currently in *

If you selected Resident, please indicate which year you are currently in. *

Please enter your own information in the table below.

Then, include the details for each of your guests (spouse, partner, child(ren), grandchild(ren), etc.).

Name of Attendee *	DRMB Member? *	Age if under 18 *	Meal Selection *

Allergies and/or Dietary Restrictions

Meal also includes: Drink, Chips and Dessert

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