2015 CONFERENCE REGISTRATION FORM

Transcription

2015 CONFERENCE REGISTRATION FORM
YOUR PERSONAL INFORMATION
First Name
Surname
Address
Suburb
Postcode
State
Country
Phone (day)
Email
ADDITIONAL DELEGATES – FAMILY MEMBERS & CARERS
First Name
Surname
Phone
Email
First Name
Surname
Phone
Email
The Australasian Mastocytosis Society (INC9896639)
PO Box 865, Port Macquarie NSW 2444 | T. +61 2 6583 5080 | info@mastocytosis.com.au
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First Name
Surname
Phone
Email
STATUS – Please tick the relevant statement:
☐ I am a sufferer
☐ I am a carer
☐ I am a medical professional
FIELD:
DIAGNOSIS – Please tick your diagnosis or that of the person you care for, if applicable.
☐ Cutaneous Mastocytosis
☐ Systemic Mastocytosis
☐ Aggressive Systemic Mastocytosis
☐ Mast Cell Activation Disorder (MCAD)
EMERGENCY CONTACT AND DETAILS
Name
Mobile
Relationship
Do we need to contact your GP or specialist (info below in research)?
Do you suffer from Anaphylaxis?
☐ Yes
☐ Yes
☐ No
☐ No
Please list your allergies:
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Is there any other information we need to know about your health and possible emergency situations?
BECOME A MEMBER OF THE AUSTRALASIAN MASTOCYTOSIS SOCIETY (TAMS)
Receive regular updates via the TAMS website, discounts for future events (2016 conference etc), quarterly TAMS
E-Newsletter, member of online and face-to-face support groups and more. Please select your membership
category or categories:
☐ Individual Member ($25 per year) Name:
☐ Additional Family Member x ___ ($5 per year per additional family member/carer)
Name:
QUESTIONS / COMMENTS
AMOUNT OWING
$190
No. of
delegates
$
$225
$
Non-member with ‘Easter Special’ price (payment must be received by 6 th April 2015)
$215
$
Member’s price post 7th April 2015 registration
$245
$
Non-members price post 7th April 2015 registration
$100
$
Day Only – MUST nominate the day of choice -
$50
$
Day only – SUNDAY ONLY
$
Membership/s
Per person
Delegate category
Member’s price with ‘Easter Special’ (payment must be received by 6 th April 2015)
FRIDAY
SATURDAY
TOTAL $
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PAYMENT
☐ Cheque or Money Order made out to “The Australasian Mastocytosis Society” attached to form
Post this to: PO Box 865
Port Macquarie NSW 2444
 EFT (Electronic Funds Transfer)
Account Name: The Australasian Mastocytosis Society
BSB: 802 214
Account #: 132471
 PayPal via the link on our website – don’t forget to tag your payment with your name and 2015
Conference registration
AGREEMENTS – In submitting this form, I agree:
☐ Not wear perfume or aftershave to the conference or related events
☐ If I cancel my attendance a 10% fee will be retained to cover administration costs
NOTE: When completing this form, simply insert the required information into the spaces provided, then save it to
your own computer documents file. This form can then simply be attached to an email and sent directly to the
committee at info@mastocytosis.com.au
Should you have any further questions, or specific requests for assistance in caring for children during the
conference weekend, please also email the TAMS committee directly. Once we have a clearer idea of the needs
for child care, the necessary arrangements and associated charges can be determined.
Please continue to complete the additional registration information pages below. This additional information will
assist TAMS with future planning.
Thank you. We look forward to seeing you in Sydney.
The TAMS Committee
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RESEARCH
The below information will be added to the National Medical Professional Database for Mastocytosis and Mast Cell
Activation Disorders. Your personal information will not be included. Please provide information on:
General Practitioner (GP)
Name
Address
Telephone
Email
Haematologist
Name
Address
Telephone
Email
Immunologist
Name
Address
Telephone
Email
Endocrinologist
Name
Address
Telephone
Email
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Dermatologist
Name
Address
Telephone
Email
Psychiatrist
Name
Address
Telephone
Email
Paediatrician
Name
Address
Telephone
Email
Other
Name
Address
Telephone
Email
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2015 Conference Planning Information
To assist the Committee in planning details of the conference, it would be helpful for us to know some further
information that may be specific to ensure we can cater for your individual requirements. Please assist us by
completing the questions below;
1. Do you have any mobility issues/ support requirements? _________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
2. Please list any allergies, food intolerances or specific dietary needs we should be aware of when catering.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
3. Although the conference program is primarily designed around the availability of our guest presenters, it
would be helpful for us to know if you have any concerns around early / late start times etc.. eg: many
sufferers of a Mast Cell condition suffer from ‘Brain Fog’ –could this be a concern for you?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
4. Is there any specific area of information or support you are seeking from your attending this conference?
If yes, please list this below and we will endeavour to assist you or include in future conferences.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
__________________________________________________________________________ ___________________
Thank you for taking the time to assist is in the planning of our 2015 conference.
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2015 CONFERENCE REGISTRATION FORM

Transcription

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