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iCARnet CARDIAC UPDATE WEEKEND PROGRAM (PDF)

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									                             iCCnet SA Ninth Rural Weekend Update on Cardiovascular Management
                                                         Registration Form
        Delegate Information

        Family Name:_______________________________________________________________________________

        Title (Prof/Dr/Mr/Mrs/Ms/Miss):______________First Name:___________________________________________

        Organisation:________________________________________________________________________________

        Postal Address:______________________________________________________________________________

        Suburb___________________________________________State__________________ Postcode____________

        Tel (________)_________________________________Fax (________)_________________________________

        Mobile:______________________________Email:__________________________________________________

        Name & Institution/Practice for your name badge:____________________________________________________
        (e.g. Chris Jones, Adelaide Hospital)


        Special Requirements (dietary/other): ____________________________________________________________

        ___________________________________________________________________________________________

        Meeting Registration
                                       General Practitioners/Nursing Staff:   No Charge
                                                  Accompanying Partner:       $90.00 per adult
                                                 Accompanying Children:       $30.00 per child
                                                            Social Events:    No Additional Charge

        Accompanying Partner - $90.00 per person

        Family Name:________________________________________________________________________________

        Title (Prof/Dr/Mr/Mrs/Ms/Miss):______________First Name:___________________________________________

        Name for your name badge:_____________________________________________________________________
        (e.g. Chris Jones)

        Special Requirements (dietary/other): _____________________________________________________________

        ___________________________________________________________________________________________

                                                          Subtotal – Accompanying Partner                $________._____

        Accompanying Children - $30.00 per child

                                  Name                              Age          Special Requirements (dietary or otherwise)




                                                          Subtotal – Accompanying Children               $________._____
Registration 4May10
     Registration Information

                      Date                        Function                       Attendance          No.
                                                                              (please indicate)   Attending

        Delegate

        Saturday 21st August      Lunch                                        Yes       No

        Saturday 21st August      Evening Wine Tasting (6:30-7:30 pm)          Yes       No

        Saturday 21st August      Dinner (7:30 pm to late)                     Yes       No

        Accompanying Partner

        Saturday 21st August      Lunch                                        Yes       No

        Saturday 21st August      Winery Tour Bus Trip (numbers permitting)
                                   1:00 pm Bus departs                         Yes       No
                                   5:00 pm Approximate time of return

        Saturday 21st August      Evening Wine Tasting (6:30-7:30 pm)          Yes       No

        Saturday 21st August      Dinner (7:30 pm to late)                     Yes       No

        Children

        Saturday 21st August      Lunch                                        Yes       No

        Saturday 21st August      Picnic Lunch, See the Performing Sheep       Yes       No
                                  Dogs Show at Norm’s Coolies & Visit the
                                  Whispering Wall.


        Saturday 21st August      Dinner (approximately 6:00/6:30pm)           Yes       No

        Concurrent Special Interest Sessions

        Saturday 21st August      GP session on ECG Interpretation             Yes       No
        9:30am -12:00pm           with Dr Philip Tideman and Dr Julian
                                  Vaile


        Saturday 21st August      Nurse session on ECG Interpretation
        9:30am -12:00pm           with Sharon Burns (CSC, Cardiac Care         Yes       No
                                  Unit, FMC)




Registration 4May10
                                                      ACCOMMODATION
        Novotel Barossa Valley Resort
        Golf Links Road, Rowland Flat
                  Single         Double/Twin Share       Double/Twin Share          Triple Share
              Studio Rooms         Studio Rooms       Two Bedroom Apartments Two Bedroom Apartments
               $285.00/night       $303.00/night            $403.00/night           $421.00/night
        Room rate per night includes a fully cooked breakfast in Harry’s Restaurant
        Rollaway beds are an additional $58.00 per person
        Children under 15 years of age are complimentary
        Check in available from 2:00 pm Saturday 21st August
        Check out at 11:00 am Sunday 22nd August

                      Accommodation must be booked directly through the Novotel Barossa using the
                               attached Hotel Accommodation Booking Request Form.
               (Please ensure that you identify yourself as a participant of iCCnet SA’s Ninth Rural
                               Weekend Update on Cardiovascular Management)

        _______________________________________________________________________________________________________

        Payment Summary for Accompanying Partners and Children:
                                        Accompanying Partner       $________________

                                        Accompanying Children      $________________

                                   Total Amount of Cheque         $_______________


                                                                Please make cheques payable to: iCARnet.
                                                                    Credit card payment facilities are not available
        _______________________________________________________________________________________________________

        Please return Registration Form to:
        iCCnet SA
        Mail Box 28, Level 3B
        Mark Oliphant Building, Science Park
        Laffer Drive
        Bedford Park SA 5042
        Telephone: 08-8201 7840
        Fax:       08-8201 7850
        Email:     HEALTH.FMCiCCnetSA@health.sa.gov.au

                                                                                RSVP by: 6th August 2010




Registration 4May10

								
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