REGISTRATION FORM / TAX INVOICE

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					                   REGISTRATION FORM / TAX INVOICE
                                    ABN 45 877 249 165
I am registering to attend “CONTINUING CONVERSATIONS ~ Updating Professional
Practice in Palliative Care” Conference 22-23 March 2012, The Pier, Geelong, Victoria.

TITLE ………      NAME ………………………….................................................................................

POSITION …………………………………                               WORKPLACE ……………………………………..

CONTACT ADDRESS for receipt of registration……………………………………………………...

………………………………………………………………....................................................................

…………………………………………………………………………………………POST CODE ………

EMAIL for news and updates on Conference…………………………………………………………

………………………………………………………………………………………………………………..

MOBILE/TELEPHONE …………………………………………………….……………………………….


COSTS:

THIS DOCUMENT BECOMES A TAX INVOICE UPON PAYMENT

TICK PAYMENT OPTIONS:
 Registration “Early Bird 1 July 2011-31 December 2011” Special Deal
                            st           st



                                                                                           $300.00
includes both days attendance & morning teas,
lunch Thurs 22 March, Canapés Thurs 22 March (including GST)


 Optional Lunch Fri 23 March (including GST)                                               $ 30.00

Total Amount                                                                                $______

Specific Dietary request ………………………………………………………………………..

 I enclose a cheque/money order (payable to Barwon Health)

 Please charge my Credit Card

Diners              MasterCard                 Visa         Amex □

Card Holder’s Name: ……………………………......................


Card No:      
Expiry Date: ………/………/………

Signature: ………………………………………………………….



                                                                                                    Page 1 of 2
                                      CONFERENCE PROGRAM

                            DAY ONE – Thursday 22nd March 2012

10.00am – 11.00am             REGISTRATION and MORNING TEA
11.00am – 11.15am             Welcome
11.15am – 12.15pm             Key Note Speaker
                              Professor Glennys Howarth, University of Plymouth
12.20pm – 1.20pm              Key Note Speaker
                              Dr Jonathon Silverman, University of Cambridge
1.25pm – 2.30pm               LUNCH
2.30pm – 3.30pm               Workshop Speaker Stream 1A Workshop Stream 1B
                              Professor David Ashley         Dr Bruce Rumbold
3.35pm – 4.35pm               Workshop Speaker Stream 2A Workshop Speaker Stream 2B
                              Professor Phyllis Butow        Professor Michael Ashby
4.45pm – 7.00pm               CANAPES and DRINKS (Optional)

                              DAY TWO – Friday 23rd March 2012

8.30am – 9.00am               TEA/COFFEE on arrival
9.00am – 10.00am              Key Note Speaker
                              Professor Phyllis Butow, University of Sydney
10.05am – 11.05am             Workshop Speaker Stream 3A Workshop Speaker Stream 3B
                              Professor Glennys Howarth       Assoc Prof Peter Martin
                                                              “Palliation of Dysnoea”
11.05am – 11.35am             MORNING TEA
11.40am – 12.40pm             Workshop Speaker Stream 4A Workshop Speaker Stream 4B
                              Dr Jonathon Silverman           TBC
12.45pm – 1.45pm              Key Note Speaker
                              Professor Michael Ashby, University of Tasmania
1.45pm – 2.00pm               CONCLUSION
2.00pm – 3.00pm               LUNCH (Optional)


PLEASE NOTE – The Conference Program begins at 11.00am Thursday 22 March 2012,
and concludes at 2.00pm Friday 23 March 2012.


PLEASE FORWARD REGISTRATION with PAYMENT:
By email to heatherca@barwonhealth.org.au
Or by postal mail to Heather Cameron, Conference Organiser, Barwon Health Palliative Care Program, Wing C – De Forest House,
McKellar Centre, 45-95Ballarat Road, North Geelong, VIC 3219
Confirmation letters and receipts will be forwarded to you.




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