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2015 Registration form

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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 financedepatment@ccdhb.org.nz. 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 wrcsse@ccdhb.org.nz 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.
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