Please Note Only One Application Per Form

Capricornia Medical Science Conference 7 - 9 June 2013 Delegate Registration Form

Please Note only one application per form. Photocopied forms are acceptable.

DELEGATE PARTICULARS

Title:Prof. Dr. Mr. Mrs. Ms _____Family Name ______First Name ______

Organisation: ______

Address : ______

City: ______Postcode: ______Country: ______

Tel/Business ( ) ______Fax: (___) ______

Tel/Home: ( ) ______Email : ______

Preferred Name for Name Badge ______

Special Dietary or Disability Requirements: ______

Partner/Guest: Title ______Family Name ______First Name ______

A. REGISTRATION FEES

Full conference (Fri, Sat, Sun, )

2 day Registration (Sat & Sun) …………………………………………….. $290.00

1 Day registration (Sat or Sun) …………………………………………….. $145.00

** Please indicate which day: Saturday ______Sunday ______

A. WORKSHOPS Mycology (Friday) …………………………………. $85.00  Please tick. Microbiology (Sat AM) ………………………………… $50.00  Haematology (Friday) ………………………………… $75.00  Immunohaematology (Sat) ………………………………… FREE  Phlebotomy (Sun) ………………………………… $110.00  Immunohistochemistry (Sat) ………………………………… FREE  Serology/Virology (Friday) …………………………………… $120.00  S.I.G Meeting

Total Section A $______B. ACCOMMODATION

For accommodation options see accompanying documents, contact Mercure Capricorn International Resort Queensland Australia, or the conference website. Where room features allow more than two persons per room, the price per person becomes less than that shown, however additional breakfasts may need to be purchased. Please mention this conference when placing your booking directly with the Resort to obtain these discounted rates. These rates are also available to Resort guests staying Pre or Post conference.

All rates quoted are per person per night (room and breakfast). Twin share prices are based on 2 persons per room.

Accommodation Requirements – Bed & Breakfast ALL ACCOMMODATION BOOKED DIRECT WITH THE RESERVATIONS DEPARTMENT ON 1800 075 902 & WILL BE TO INDIVIDUAL ACCOUNTS

Room Type Single Share, per room per Double/Twin Share, per room night per night Standard Queen Room $146.00 $167.00 Standard Twin Room $146.00 $167.00 Superior Room $176.00 $197.00 Superior Kitchenette Room $206.00 $227.00 Superior with Ocean View $206.00 $227.00 Superior Suite Lagoon View $236.00 $248.00 Superior Kitchenette Suite $236.00 $248.00 One Bedroom Apartment $236.00 $248.00 Two Bedroom Apartment $266.00 $287.00

Check-in Date: ______Check-out Date: ______No. Room nights ______

Sharing with: ______and ______

The resort offers a range of premium accommodation from rooms to self-contained apartments with views overlooking the ocean, the lush subtropical gardens or lagoon swimming pool.All accommodation types feature in-house movies and internet access. List of rooms

 Standard one Queen-size bed Our comfortable standard rooms, which accommodate up to 2 adults or 1 adult and 1 child, feature a queen sized bed, air conditioning and a private balcony which overlooks either the lush subtropical gardens or lagoon swimming pool.  Superior 1 Queen Bed and 2 Single Bed Our spacious superior suites, which accommodate up to 2 adults and 2 children, feature a queen sized bed and two single beds, air conditioning and a private balcony which overlooks either the lush subtropical gardens or lagoon swimming pool.  Superior 1 Queen and 2 Single Beds with Ocean V iew Our comfortable superior rooms, which accommodate up to 2 adults and 2 children, feature a queen sized bed and two single beds, air conditioning and a private balcony which overlooks either the Ocean and Keppel Island Group.  Superior Suite 1 Queen Bed Lagoon View Our spacious superior suites, which accommodate up to 2 adults and 2 children, feature a queen sized bed and two single beds, air conditioning and a private balcony which overlooks either the lush subtropical gardens or lagoon swimming pool.  Superior 1 Queen and 2 singles Kitchenette Our spacious Superior Kitchenette Suite overlooks the Japanese garden and features a queen-size bed in the front room and two single beds in second bedroom. The kitchenette offers the convenience of stove and microwave and basic kitchen utensils.  1 Bedroom Apartment 1 Queen and 2 Single Beds Our spacious superior apartments, which accommodate up to 2 adults and 2 children, feature a queen sized bed and two single beds, self contained kitchen, shower over bath and a private balcony which overlooks either the lush gardens or ocean. C. OPTIONAL EVENTS Full Delegate *Partner/guests

Friday Welcome Party $40 $50 (drinks + light supper)

Saturday Dinner at Fern’s Hide-away Restraurant, Byfield $65 $85

*please indicate both delegate + partner requirements for catering purposes.

Total Section D PAYMENT OF FEES

Note: Your registration will be confirmed only upon receipt of payment. Conference Australian Business Number (ABN): 78 247 698 332

Registration Fees Total Section A

Workshops Total Section B

Accommodation (payment direct to Rydges)

Optional Events Total Section D

GRAND TOTAL ENCLOSED $ ______

Cheque payment: All cheques must be made payable to “Capricornia Medical Science Association”

Credit card payment: Bankcard  Visa  Mastercard 

Cardholder name : ______

Card number: ______/______/______/______

Expiry Date: ______/______Signature ______

Please send the completed Registration Form and payment to:

Capricornia Medical Science Association Att: Ms Larissa Ramm QHPS Laboratory Rockhampton Hospital Rockhampton, QLD Australia 4700 FAX : +61 7 49207315 Email: [email protected]

Cancellation Policy: All conference registration cancellations must be advised in writing to the CMSA conference manager. Cancellations received by 16/05/2013 will incur a $20 cancellation fee. Cancellations made after 20 May incur a penalty of 40% off the fee paid. No refunds will be give after 1 June. The organisers, sponsors and their agents, either jointly or singularly reserve the right to alter this programme and registration form without notice and will not accept responsibility for any error, omissions or changes.