Fremantle Conference

Fremantle Conference
Tradewinds Hotel, Fremantle | 18 October 2014
Payment options
CONFERENCE REGISTRATION FORM
TOTAL PAYABLE
Please charge the total payable amount above to the following credit card
Visa or Mastercard only
Visa
Mastercard Card number
Post toRural Health West
PO Box 433 Nedlands WA 6909
T 08 6389 4525
F 08 6389 4501
E events@ruralhealthwest.com.au
Fremantle Conference
$
Expiry date
gram
o
r
P
y
l
Fami stration
Regi inside
Form
18 October 2014
Tradewinds Hotel, Fremantle
/
Name of cardholder (Please print clearly.)
Title
First name
Surname
Practice/organisation
Cardholder’s signature
Job title
Address
Western Australian Centre for Remote and Rural Medicine Limited trading as Rural Health West • ABN 29 123 188 367
TF ME
Special dietary requirements
Accompanying partner’s name
Children and ages
Permission to Act in Case of Emergency or Accident Form
Special dietary requirements
Professional College registration number
RACGP number
ACRRM number
Transport
Complimentary bus transfers will be provided for those delegates staying in the Fremantle CBD and not at the conference venue. The
bus will depart at 7.45am from The Esplanade Hotel Fremantle – by Rydges. The bus will depart the Tradewinds Hotel at 5.30pm.
Please indicate here if you require bus transfers.
Rural Health West Fremantle Conference – 18 October 2014
Although every care will be taken of your child/children, neither Rural Health West nor the Family Support Program can
be held responsible for any accident which may occur. In the event of any accident or illness, every attempt will be made
to contact parents before medical treatment is sought. However, should this prove impossible, it will be necessary for
authority to be given for treatment to be undertaken. Parents are asked to sign below.
I,
authorise the staff of Rural Health West to seek
emergency medical treatment for my child/children should this be considered necessary.
Yes, I require bus transfers
Registration fees
PROGRAM OVERVIEW AND
REGISTRATION FORM
(Early Bird registration closing date: Friday 19 September 2014)
Early Bird (by 19 September 2014) $550 including GST
Name and ages of child/children (please note any health issues carers should know about).
Standard (after 19 September 2014) $600 including GST
Choose the stream you would like to attend for the day
TIME
STREAM
SignedDate
Mother’s mobile phone
Father’s mobile phone
8.30am-5.00pm
Obstetrics ultrasound
8.30am-5.00pm
Surgical and practical medicine
Completed Permission to Act in Case of Emergency or Accident Form and Family Program Registration Form must be
signed and returned to:
8.30am-5.00pm
Orthopaedic emergencies
8.30am-5.00pm
Emergency medicine
8.30am-5.00pm
Diabetes
Rural Health West
PO Box 433
Nedlands Western Australia 6909
T 08 6389 4500
F 08 6389 4501
Efamilysupport@ruralhealthwest.com.au
rt B
a: Po
strali
u
A
n
r
ste
Photo courtesy Tourism We
e
.
tle
an
m
e
, Fr
ach
Fremantle Conference
Fremantle Conference
Tradewinds Hotel, Fremantle | 18 October 2014
Tradewinds Hotel, Fremantle | 18 October 2014
FAMILY PROGRAM REGISTRATION FORM
CONFERENCE REGISTRATION FORM
Post toRural Health West
PO Box 433 Nedlands WA 6909
Choose your stream for the day
Doctor’s name
M
E
Spouse’s name
M
E
Child’s name
Child’s name
Age
Obstetrics
ultrasound
Surgical and
practical
medicine
Orthopaedic
emergencies
Emergency
medicine
Diabetes
MaleFemale
Child’s name
We are staying at:
General practitioners have a choice of five workshop
streams:
l
Obstetrics ultrasound
l
Surgical and practical medicine
l
Orthopaedic emergencies
l
Emergency medicine
lDiabetes
Each workshop stream will include interactive clinical
updates, hands-on upskilling and small group learning
opportunities that have been specifically designed for rural
and remote practitioners.
Visa or Mastercard only
MaleFemale
Child’s name
Special requirements
The Fremantle Conference program includes a diverse
range of workshop streams across a number of Active
Learning Modules, relevant to general practice.
Age
Special requirements
MaleFemale
Payment options
Expiry date
Age
Other
Time
Activity
Cost (including GST)
Number attending
Cancellation policy
If registration is cancelled by 5 September 2014 a full refund is given. If registration is cancelled after 5 September 2014
a refund of 50 per cent is given. Refunds will not be issued for any registrations cancelled after 26 September 2014.
Sub-total
Children 0 to 4 years
8.15am-12.45pm
12.45pm-5.00pm
In-house care
In-house care
$30.00 (per child/
per session)
Travel
Rural Health West will provide travel support for currently practising doctors who work in rural and remote Western
Australia and their spouses/partners. For more information, please see the travel information document on the
conference web page www.ruralhealthwest.com.au/conferences.
$
$30.00 (per child/
per session)
$
Accommodation options
Children 5 and over
Chipmunks Playland
and Café, Cockburn
Delegates will be responsible for booking their own accommodation. A block booking has been made at the
conference venue for those delegates wishing to stay onsite.
$32.00 (one child)
$
Spouse/partner
10.00am-12.00pm
Fremantle Walking Tour
$40.00 (one adult)
$
Rural Health West’s main funding sources are the Australian Government Department of Health and the Western Australian
Department of Health (WA Country Health Service).
$
Western Australian Centre for Remote and Rural Medicine Limited trading as Rural Health West • ABN 29 123 188 367
To view or download the full program visit www.ruralhealthwest.com.au/conferences
Cut along this line
Cut along this line
9.30am-12.45pm
TOTAL
To view or download the full program visit www.ruralhealthwest.com.au/conferences
/
Cardholder’s signature
Saturday 18 October 2014
Each workshop stream will be limited to a maximum of 15
delegates. Applications have been made for RACGP and
ACRRM professional development category 1 points for
this conference as well as for the Rural Procedural Grants
Program.
Please contact your relevant College before attending this
conference if you wish to apply for the grant.
Mastercard Name of cardholder (Please print clearly.)
MaleFemale
The Esplanade Hotel Fremantle by Rydges
Visa
Western Australian Centre for Remote and Rural Medicine Limited trading as Rural Health West • ABN 29 123 188 367
A CPR update will feature in the surgical and practical
medicine workshop stream.
Applications have been made for RACGP and ACRRM professional
development category 1 points for this conference as well as for
the Rural Procedural Grants Program. Activity number pending.
$
Card number
Special requirements
Tradewinds Hotel
TOTAL PAYABLE
Please charge the total payable amount above to the following credit card
Special requirements
Age
Privacy statement
The Privacy Act 2014 provides that before your personal contact details can be published or made available
to major sponsors, exhibitors and other parties directly related to the conference, you must give your consent.
If you do consent to your contact details being provided to the above mentioned parties, please tick this box.
T 08 6389 4525
F 08 6389 4501
E events@ruralhealthwest.com.au
Tradewinds Hotel, Fremantle
Telephone 08 9339 8188 | www.tradewindshotel.com.au
The Tradewinds Hotel combines a great location with a choice of spacious and comfortable hotel rooms and short
stay apartments. The popular alfresco courtyard is part of the Tradewinds bar and restaurant. It is a delightful setting,
day or night overlooking the Indian Ocean beyond Fremantle harbour.
$220.00 room only
$230.00 bed and breakfast – 1 guest
$250.00 bed and breakfast – 2 guests
Breakfast purchased in the restaurant (not part of accommodation package) is $26.00 per person. Please contact the
Tradewinds Hotel, Fremantle directly regarding room availability and apartment costs.
Fremantle Conference
Fremantle Conference
Tradewinds Hotel, Fremantle | 18 October 2014
Tradewinds Hotel, Fremantle | 18 October 2014
FAMILY PROGRAM REGISTRATION FORM
CONFERENCE REGISTRATION FORM
Post toRural Health West
PO Box 433 Nedlands WA 6909
Choose your stream for the day
Doctor’s name
M
E
Spouse’s name
M
E
Child’s name
Child’s name
Age
Obstetrics
ultrasound
Surgical and
practical
medicine
Orthopaedic
emergencies
Emergency
medicine
Diabetes
MaleFemale
Child’s name
We are staying at:
General practitioners have a choice of five workshop
streams:
l
Obstetrics ultrasound
l
Surgical and practical medicine
l
Orthopaedic emergencies
l
Emergency medicine
lDiabetes
Each workshop stream will include interactive clinical
updates, hands-on upskilling and small group learning
opportunities that have been specifically designed for rural
and remote practitioners.
Visa or Mastercard only
MaleFemale
Child’s name
Special requirements
The Fremantle Conference program includes a diverse
range of workshop streams across a number of Active
Learning Modules, relevant to general practice.
Age
Special requirements
MaleFemale
Payment options
Expiry date
Age
Other
Time
Activity
Cost (including GST)
Number attending
Cancellation policy
If registration is cancelled by 5 September 2014 a full refund is given. If registration is cancelled after 5 September 2014
a refund of 50 per cent is given. Refunds will not be issued for any registrations cancelled after 26 September 2014.
Sub-total
Children 0 to 4 years
8.15am-12.45pm
12.45pm-5.00pm
In-house care
In-house care
$30.00 (per child/
per session)
Travel
Rural Health West will provide travel support for currently practising doctors who work in rural and remote Western
Australia and their spouses/partners. For more information, please see the travel information document on the
conference web page www.ruralhealthwest.com.au/conferences.
$
$30.00 (per child/
per session)
$
Accommodation options
Children 5 and over
Chipmunks Playland
and Café, Cockburn
Delegates will be responsible for booking their own accommodation. A block booking has been made at the
conference venue for those delegates wishing to stay onsite.
$32.00 (one child)
$
Spouse/partner
10.00am-12.00pm
Fremantle Walking Tour
$40.00 (one adult)
$
Rural Health West’s main funding sources are the Australian Government Department of Health and the Western Australian
Department of Health (WA Country Health Service).
$
Western Australian Centre for Remote and Rural Medicine Limited trading as Rural Health West • ABN 29 123 188 367
To view or download the full program visit www.ruralhealthwest.com.au/conferences
Cut along this line
Cut along this line
9.30am-12.45pm
TOTAL
To view or download the full program visit www.ruralhealthwest.com.au/conferences
/
Cardholder’s signature
Saturday 18 October 2014
Each workshop stream will be limited to a maximum of 15
delegates. Applications have been made for RACGP and
ACRRM professional development category 1 points for
this conference as well as for the Rural Procedural Grants
Program.
Please contact your relevant College before attending this
conference if you wish to apply for the grant.
Mastercard Name of cardholder (Please print clearly.)
MaleFemale
The Esplanade Hotel Fremantle by Rydges
Visa
Western Australian Centre for Remote and Rural Medicine Limited trading as Rural Health West • ABN 29 123 188 367
A CPR update will feature in the surgical and practical
medicine workshop stream.
Applications have been made for RACGP and ACRRM professional
development category 1 points for this conference as well as for
the Rural Procedural Grants Program. Activity number pending.
$
Card number
Special requirements
Tradewinds Hotel
TOTAL PAYABLE
Please charge the total payable amount above to the following credit card
Special requirements
Age
Privacy statement
The Privacy Act 2014 provides that before your personal contact details can be published or made available
to major sponsors, exhibitors and other parties directly related to the conference, you must give your consent.
If you do consent to your contact details being provided to the above mentioned parties, please tick this box.
T 08 6389 4525
F 08 6389 4501
E events@ruralhealthwest.com.au
Tradewinds Hotel, Fremantle
Telephone 08 9339 8188 | www.tradewindshotel.com.au
The Tradewinds Hotel combines a great location with a choice of spacious and comfortable hotel rooms and short
stay apartments. The popular alfresco courtyard is part of the Tradewinds bar and restaurant. It is a delightful setting,
day or night overlooking the Indian Ocean beyond Fremantle harbour.
$220.00 room only
$230.00 bed and breakfast – 1 guest
$250.00 bed and breakfast – 2 guests
Breakfast purchased in the restaurant (not part of accommodation package) is $26.00 per person. Please contact the
Tradewinds Hotel, Fremantle directly regarding room availability and apartment costs.
Fremantle Conference
Fremantle Conference
Tradewinds Hotel, Fremantle | 18 October 2014
Tradewinds Hotel, Fremantle | 18 October 2014
FAMILY PROGRAM REGISTRATION FORM
CONFERENCE REGISTRATION FORM
Post toRural Health West
PO Box 433 Nedlands WA 6909
Choose your stream for the day
Doctor’s name
M
E
Spouse’s name
M
E
Child’s name
Child’s name
Age
Obstetrics
ultrasound
Surgical and
practical
medicine
Orthopaedic
emergencies
Emergency
medicine
Diabetes
MaleFemale
Child’s name
We are staying at:
General practitioners have a choice of five workshop
streams:
l
Obstetrics ultrasound
l
Surgical and practical medicine
l
Orthopaedic emergencies
l
Emergency medicine
lDiabetes
Each workshop stream will include interactive clinical
updates, hands-on upskilling and small group learning
opportunities that have been specifically designed for rural
and remote practitioners.
Visa or Mastercard only
MaleFemale
Child’s name
Special requirements
The Fremantle Conference program includes a diverse
range of workshop streams across a number of Active
Learning Modules, relevant to general practice.
Age
Special requirements
MaleFemale
Payment options
Expiry date
Age
Other
Time
Activity
Cost (including GST)
Number attending
Cancellation policy
If registration is cancelled by 5 September 2014 a full refund is given. If registration is cancelled after 5 September 2014
a refund of 50 per cent is given. Refunds will not be issued for any registrations cancelled after 26 September 2014.
Sub-total
Children 0 to 4 years
8.15am-12.45pm
12.45pm-5.00pm
In-house care
In-house care
$30.00 (per child/
per session)
Travel
Rural Health West will provide travel support for currently practising doctors who work in rural and remote Western
Australia and their spouses/partners. For more information, please see the travel information document on the
conference web page www.ruralhealthwest.com.au/conferences.
$
$30.00 (per child/
per session)
$
Accommodation options
Children 5 and over
Chipmunks Playland
and Café, Cockburn
Delegates will be responsible for booking their own accommodation. A block booking has been made at the
conference venue for those delegates wishing to stay onsite.
$32.00 (one child)
$
Spouse/partner
10.00am-12.00pm
Fremantle Walking Tour
$40.00 (one adult)
$
Rural Health West’s main funding sources are the Australian Government Department of Health and the Western Australian
Department of Health (WA Country Health Service).
$
Western Australian Centre for Remote and Rural Medicine Limited trading as Rural Health West • ABN 29 123 188 367
To view or download the full program visit www.ruralhealthwest.com.au/conferences
Cut along this line
Cut along this line
9.30am-12.45pm
TOTAL
To view or download the full program visit www.ruralhealthwest.com.au/conferences
/
Cardholder’s signature
Saturday 18 October 2014
Each workshop stream will be limited to a maximum of 15
delegates. Applications have been made for RACGP and
ACRRM professional development category 1 points for
this conference as well as for the Rural Procedural Grants
Program.
Please contact your relevant College before attending this
conference if you wish to apply for the grant.
Mastercard Name of cardholder (Please print clearly.)
MaleFemale
The Esplanade Hotel Fremantle by Rydges
Visa
Western Australian Centre for Remote and Rural Medicine Limited trading as Rural Health West • ABN 29 123 188 367
A CPR update will feature in the surgical and practical
medicine workshop stream.
Applications have been made for RACGP and ACRRM professional
development category 1 points for this conference as well as for
the Rural Procedural Grants Program. Activity number pending.
$
Card number
Special requirements
Tradewinds Hotel
TOTAL PAYABLE
Please charge the total payable amount above to the following credit card
Special requirements
Age
Privacy statement
The Privacy Act 2014 provides that before your personal contact details can be published or made available
to major sponsors, exhibitors and other parties directly related to the conference, you must give your consent.
If you do consent to your contact details being provided to the above mentioned parties, please tick this box.
T 08 6389 4525
F 08 6389 4501
E events@ruralhealthwest.com.au
Tradewinds Hotel, Fremantle
Telephone 08 9339 8188 | www.tradewindshotel.com.au
The Tradewinds Hotel combines a great location with a choice of spacious and comfortable hotel rooms and short
stay apartments. The popular alfresco courtyard is part of the Tradewinds bar and restaurant. It is a delightful setting,
day or night overlooking the Indian Ocean beyond Fremantle harbour.
$220.00 room only
$230.00 bed and breakfast – 1 guest
$250.00 bed and breakfast – 2 guests
Breakfast purchased in the restaurant (not part of accommodation package) is $26.00 per person. Please contact the
Tradewinds Hotel, Fremantle directly regarding room availability and apartment costs.
Fremantle Conference
Tradewinds Hotel, Fremantle | 18 October 2014
Payment options
CONFERENCE REGISTRATION FORM
TOTAL PAYABLE
Please charge the total payable amount above to the following credit card
Visa or Mastercard only
Visa
Mastercard Card number
Post toRural Health West
PO Box 433 Nedlands WA 6909
T 08 6389 4525
F 08 6389 4501
E events@ruralhealthwest.com.au
Fremantle Conference
$
Expiry date
gram
o
r
P
y
l
Fami stration
Regi inside
Form
18 October 2014
Tradewinds Hotel, Fremantle
/
Name of cardholder (Please print clearly.)
Title
First name
Surname
Practice/organisation
Cardholder’s signature
Job title
Address
Western Australian Centre for Remote and Rural Medicine Limited trading as Rural Health West • ABN 29 123 188 367
TF ME
Special dietary requirements
Accompanying partner’s name
Children and ages
Permission to Act in Case of Emergency or Accident Form
Special dietary requirements
Professional College registration number
RACGP number
ACRRM number
Transport
Complimentary bus transfers will be provided for those delegates staying in the Fremantle CBD and not at the conference venue. The
bus will depart at 7.45am from The Esplanade Hotel Fremantle – by Rydges. The bus will depart the Tradewinds Hotel at 5.30pm.
Please indicate here if you require bus transfers.
Rural Health West Fremantle Conference – 18 October 2014
Although every care will be taken of your child/children, neither Rural Health West nor the Family Support Program can
be held responsible for any accident which may occur. In the event of any accident or illness, every attempt will be made
to contact parents before medical treatment is sought. However, should this prove impossible, it will be necessary for
authority to be given for treatment to be undertaken. Parents are asked to sign below.
I,
authorise the staff of Rural Health West to seek
emergency medical treatment for my child/children should this be considered necessary.
Yes, I require bus transfers
Registration fees
PROGRAM OVERVIEW AND
REGISTRATION FORM
(Early Bird registration closing date: Friday 19 September 2014)
Early Bird (by 19 September 2014) $550 including GST
Name and ages of child/children (please note any health issues carers should know about).
Standard (after 19 September 2014) $600 including GST
Choose the stream you would like to attend for the day
TIME
STREAM
SignedDate
Mother’s mobile phone
Father’s mobile phone
8.30am-5.00pm
Obstetrics ultrasound
8.30am-5.00pm
Surgical and practical medicine
Completed Permission to Act in Case of Emergency or Accident Form and Family Program Registration Form must be
signed and returned to:
8.30am-5.00pm
Orthopaedic emergencies
8.30am-5.00pm
Emergency medicine
8.30am-5.00pm
Diabetes
Rural Health West
PO Box 433
Nedlands Western Australia 6909
T 08 6389 4500
F 08 6389 4501
Efamilysupport@ruralhealthwest.com.au
rt B
a: Po
strali
u
A
n
r
ste
Photo courtesy Tourism We
e
.
tle
an
m
e
, Fr
ach
Fremantle Conference
Tradewinds Hotel, Fremantle | 18 October 2014
Payment options
CONFERENCE REGISTRATION FORM
TOTAL PAYABLE
Please charge the total payable amount above to the following credit card
Visa or Mastercard only
Visa
Mastercard Card number
Post toRural Health West
PO Box 433 Nedlands WA 6909
T 08 6389 4525
F 08 6389 4501
E events@ruralhealthwest.com.au
Fremantle Conference
$
Expiry date
gram
o
r
P
y
l
Fami stration
Regi inside
Form
18 October 2014
Tradewinds Hotel, Fremantle
/
Name of cardholder (Please print clearly.)
Title
First name
Surname
Practice/organisation
Cardholder’s signature
Job title
Address
Western Australian Centre for Remote and Rural Medicine Limited trading as Rural Health West • ABN 29 123 188 367
TF ME
Special dietary requirements
Accompanying partner’s name
Children and ages
Permission to Act in Case of Emergency or Accident Form
Special dietary requirements
Professional College registration number
RACGP number
ACRRM number
Transport
Complimentary bus transfers will be provided for those delegates staying in the Fremantle CBD and not at the conference venue. The
bus will depart at 7.45am from The Esplanade Hotel Fremantle – by Rydges. The bus will depart the Tradewinds Hotel at 5.30pm.
Please indicate here if you require bus transfers.
Rural Health West Fremantle Conference – 18 October 2014
Although every care will be taken of your child/children, neither Rural Health West nor the Family Support Program can
be held responsible for any accident which may occur. In the event of any accident or illness, every attempt will be made
to contact parents before medical treatment is sought. However, should this prove impossible, it will be necessary for
authority to be given for treatment to be undertaken. Parents are asked to sign below.
I,
authorise the staff of Rural Health West to seek
emergency medical treatment for my child/children should this be considered necessary.
Yes, I require bus transfers
Registration fees
PROGRAM OVERVIEW AND
REGISTRATION FORM
(Early Bird registration closing date: Friday 19 September 2014)
Early Bird (by 19 September 2014) $550 including GST
Name and ages of child/children (please note any health issues carers should know about).
Standard (after 19 September 2014) $600 including GST
Choose the stream you would like to attend for the day
TIME
STREAM
SignedDate
Mother’s mobile phone
Father’s mobile phone
8.30am-5.00pm
Obstetrics ultrasound
8.30am-5.00pm
Surgical and practical medicine
Completed Permission to Act in Case of Emergency or Accident Form and Family Program Registration Form must be
signed and returned to:
8.30am-5.00pm
Orthopaedic emergencies
8.30am-5.00pm
Emergency medicine
8.30am-5.00pm
Diabetes
Rural Health West
PO Box 433
Nedlands Western Australia 6909
T 08 6389 4500
F 08 6389 4501
Efamilysupport@ruralhealthwest.com.au
rt B
a: Po
strali
u
A
n
r
ste
Photo courtesy Tourism We
e
.
tle
an
m
e
, Fr
ach