CONFERENCE REGISTRATION FORM Pre-Hospital Education Conference 2007 19th of May 2007 Croke Park Conference Centre, Dublin www.crokepark.ie Participants Information (please print in clear block capitals) Title: ______Full Name (as it will appear on certificate) ________________________________ Address:________________________________________________________________ ________________________________________________________________________ Contact Telephone Number:__________________Email:_________________________ Organisation (optional): ____________________________________________________ What is your level of training? _______________________________________________ Conference fees include admission to conference, dinner (catering by Fitzers), teas, coffees, refreshments, and registration. Total fee for conference. €55.00 After the conference you can avail of an optional tour of Croke Park and the GAA museum. The tour is available to delegates who register by 4th €05.00 May 2007 Total payment € Payment Options Visa Credit Card Number: __ __ __ __/__ __ __ __/__ __ __ __/__ __ __ __ Expiry date: _____/______ Name of Cardholder: _______________________________________________________ Address: _________________________________________________________________ All Cheques should be made payable to Medicall Ambulance Ltd. Please return by post to Medicall Ambulance Service (Conference), 73/74 Dartmouth Terrace, Ranelagh, Dublin 6, e-mail to email@example.com or fax to 01-4 966 900. If you should have any difficulty in registering, require directions or public transport advice please contact firstname.lastname@example.org or 01-4 966 933. Additional Instructions Places are limited and pre registration is essential. Accommodation is available at Croke Park Jury’s 018192300. Cost per delegate is €55.00 (including hot lunch by Fitzers). Conference is open to all levels of pre-hospital care providers, doctors and nurses. Physician Continuous Medical Education Credits and An Bórd Altránais Education Credits have been applied for. This is a non-profit event sponsored by Receipts will be issued with certification of attendance on the day of the conference. Registration forms must be accompanied by full payment in order to be processed. “No shows” are non-refundable and are liable for the full registration costs. Registration is no-transferable. Delegates must be over 18 years.