ATTACHMENT & INTERACTIONAL ANALYSIS 12 – 13 August 2015 ACCOLADES BOUTIQUE VENUE | 72 DALE ROAD | MIDRAND | TEL: 087 022 0370 ______

REGISTRATION FORM Please note that a separate form is required for each delegate. Please complete by typing and then signing the registration form and fax to 086 519 8622 / [email protected] After receipt of registration form and payment, a confirmation of attendance will be emailed to the delegate. Please refer to Section B for payment information. .

SECTION A: DELEGATE INFORMATION PLEASE TYPE CLEARLY. NAMES MUST BE AS THEY MUST APPEAR ON CERTIFICATES Prof / Dr / Mr / Mrs / Ms: Surname: Initials: First Names: Registration no .HPCSA Job Title: Registration no. SACSSP Name of Institution: Postal Address: Postal

Tel.: Cell: Fax: Email:

WORKSHOP REGISTRATION INCLUDES TEAs/COFFEEs, LUNCH AND WORKSHOP MATERIALS WORKSHOP – FULL PAYMENT SPECIAL MEAL REQUIREMENT – PLEASE TICK R3 500 Kosher – surcharge R355 YES NO Halaal – surcharge R255 YES NO Vegetarian – no surcharge YES NO SECTION B: PAYMENT REGISTRATION WILL ONLY BE FINAL AFTER FULL PAYMENT HAS BEEN RECEIVED. THE DEPOSIT SLIP/ PROOF OF PAYMENT MUST BE FAXED/ EMAILED TO: 086 519 8622 / [email protected] BANK FNB ACCOUNT NAME FAMILYZONE BRANCH MY BRANCH ACCOUNT NUMBER 62416444800 BRANCH CODE 255-355 TYPE OF ACCOUNT BUSINESS REFERENCE Please remember to fill in your surname and initials as reference on the deposit slip.

Signed by: (Name of delegate) Signature: Date: RULES FOR REGISTRATION

1. The registration form is binding. Once you have signed and returned it, you are liable to pay the registration fee. 2. Registration closing dates are non-negotiable. Last day for registration is 8 August 2015. 3. The person whose name appears in the delegate information section on this form is the one who will be registered and held responsible for payment. 4. Delegates who supply the incorrect names for certificates or who require changes after certificates are issued will be charged for printing, packaging, posting and handling of certificates. 5. We reserve the right to change or cancel training if insufficient participants register for a particular event.

The toolkit will be available at the workshop for R2 000 – credit card facility available.