Registration 2015 Cost: NZ $2500 (Incl. GST) Effective Management of Anaesthetic Crises (EMAC) Contact Information First Name: Surname: Hospital/Workplace: Position: Years of Practice: (BTY1, ATY1, Fellow, Specialist etc.) Contact Phone: Email: Postal address: (For any pre-readings) Personal requirements: (i.e. Dietary requirements) Course Selection – please select from the dates below. All courses are Wednesday to Friday. 18-20 March 2015 10-12 June 2015 2-4 September 2015 11-13 November 2015 29-31 July 2015 Method of Payment Your payment will be processed approximately 6 weeks prior to the course date. Internet banking Direct Deposit a/c: 03-0584-0198101-02 Ref – YOUR NAME and 0035 Visa Card Number: MasterCard Name on Card: Expiry Date: Invoice Attention: Company Name: Postal Address: Phone #: If you require an invoice to claim costs please request from our finance department firstname.lastname@example.org. Your payment will be processed approximately six weeks prior to the course. Cheque Please make cheques payable to ‘Capital & Coast DHB’ and enclose payment with your registration. Please turn over Terms & Conditions The Wellington Regional Centre for Simulation & Skills Education reserves the right to cancel any course if the minimum number of attendees is not met, or due to circumstances beyond our control. Under those circumstances we will refund any course payments that have been received. In the event of participant cancellation 2-6 weeks before the course date course registration fees will be refunded less an administration fee of $250.00. If a participant fails to attend the course or cancels less than 2 weeks prior to the course date no refund will be issued except under exceptional circumstances as determined by management. I have read and agree to the Terms & Conditions: Signature: Name: Date: Once completed please send this form to email@example.com or post it to: The Simulation & Skills Centre, Level 9 CSB, Wellington Hospital, Private Bag 7902, Wellington. Once your application is received you will be emailed confirmation of your position on the course and a course information booklet.