Registration Form

Personal Details
Title
First Name
Surname
Preferred Name
Telephone Number
Fax Number
Mobile Number
Email
Confirm E-mail
HPCSA / PN / DT No
Postal Address
City
Postal Code
Province
Hospital/Company/Organisation
Food Allergies / Special Instructions
   
Workshops
NOT ATTENDING WORKSHOPS
 
WEDNESDAY 29 AUGUST: 10h00 - 17h00:
Respiratory Skills Workshop
The Difficult Intubation, Percutaneous Tracheostomy, Bronchoscopy & Advanced Ventilation 		 R  1 500.00
Focussed Assessment with Transthoracic Echocardiography (FATE) & Wet Lab  R  1 500.00
Ultrasound in ICU
Basic introduction, FAST & Lung, Vascular access & assessment, Upper Abdominal US 		 R  1 500.00
   
WEDNESDAY 29 AUGUST: 15h30 - 17h00
Basic Airway Management  R   100.00
 
Registration Information
Registration Type Early Bird Price (closes on 30 June 2012)
Doctors - Society Members R 2 900.00
Doctors - Non-Society Members R 3 500.00
Nurses, Physiotherapists, Students* & Allied Medical Society Members
* Attach copy of Student Card 		R 2 300.00
Nurses, Physiotherapists, Students* & Allied Medical Non-Society Members 
* Attach copy of Student Card 		R 2 900.00
Dieticians SASPEN Society Members R 2 300.00
Dieticians SASPEN Non-Society Members R 2 900.00
Day Registration Fee (Excludes Social Functions) R 1 500.00
Additional Trade Members: R 2 300
 
Social Function
Attending Welcome Function: Superbowl - Wednesday 29 August (Incl. in Registration Fee)  Yes
Attending Celebration Function: Royal Ballroom - Friday 31 August (R250pp)  Yes
Attending Informal Function: Shebeen - Saturday 1 September (Incl. in Registration Fee)  Yes
 
ACCOMPANYING PERSON:
 Accompanying Person to Social Functions:
 
 
Payment
NOTE: If registering as a group, EACH PERSON must complete a separate registration form. This booking is non-transferable, for any changes please contact +27 (0)11 317 6900. Only full prepaid registrations will be accepted by the organisers. METHODS OF PAYMENT: Please fax through proof of payment, with your name To +27 (0) 11 463 3265. Should this not be received, your booking will be invalid. Please select your method of payment.
 
Bank Deposit or EFT
Credit Card
Sponsored Delegates

Government Orders
Regrettably, government orders will not be accepted.
 
Comments
 
Cancellation Policy
Registration fees will be refunded less 10% administration fee. Cancellations must be submitted in writing no later than 27 July 2012. No cancellations will be received after this date.
 

TOTAL DUE:

ZAR 0.00