2011 AHPA 20th National Conference
Registration Form

THIS FORM IS FOR NEW REGISTRATIONS ONLY.
TO MAKE AN AMENDMENT CONTACT CONFERENCE CO-ORDINATORS
NOTE: If a duplicate form is completed you will be charged for two registrations.
Amendments or payments to a previously submitted registration must not be made by completing this form again,
please email ahpa@confco.com.au or phone 02 6292 9000.

Personal Details
    Please DO NOT type in ALL CAPS  
Title Mr, Ms, Dr, Prof Namespace
Surname
Position
Organisation
Mailing Address

 
Suburb State space spacePostcodespace
Country
Telephone Faxspace
Mobile
Delegate E-mail
Reconfirm Email Are you of Aboriginal or Torres Strait Islander Origin
Name for Badge
Special Requirements eg Diet:space
Do you have a Twitter Account ?space
 
Privacy Disclosure
I DO consent to my name to being included in the Delegates List to be distributed at the Conference (name, organisation and state only disclosed)
I DO consent to the Conference disclosing my contact information as outlined in the privacy statement.
 
Abstract Submission
IMPORTANT: This code is to be used by the person who submitted the abstract ONLY, not co-presenters or co-authors. If you have forgotten your abstract code contact Conference Co-ordinators on 02 6292 9000. This code will prevent duplicate registrations.
I have submitted an abstract and I am the contact person
My abstract code as quoted in my confirmation letter is (to be quoted by the contact person ONLY not co-presenters)
 
Full Conference Registration Fees (Excludes Indigenous Workshop)
Early (Payment received before 4 February 2011)
  Member Registration Fees** $665.00  CLOSED  
  Non Member Registration Fees $795.00  CLOSED  
  Full-Time Student or Senior Registration* $390.00  CLOSED  
Standard (Payment received before 11 March 2011)  
  Member Registration Fees** $765.00  CLOSED  
  Non Member Registration Fees $895.00   CLOSED  
  Full-Time Student or Senior Registration* $490.00  CLOSED  
Late (Payment received after 11 March 2011)
  Member Registration Fees** $865.00    
  Non Member Registration Fees $995.00    
  Full-Time Student or Senior Registration* $590.00    
       
Day Conference Registration Fees
      
Early (Payment received before 4 February 2011)
  Member Registration Fees** $265.00  CLOSED  
  Non Member Registration Fees $365.00  CLOSED  
Standard (Payment received before 11 March 2011)        
  Member Registration Fees** $365.00  CLOSED  
  Member Registration Fees $465.00  CLOSED  
Late (Payment received after 11 March 2011)    
  Member Registration Fees** $465.00    
  Non Member Registration Fees $565.00    
Indicate which day you will be attending
 
Total
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*Student/Senior Registration Fees
You must be a full time student to qualify for the student rate.  Your registration form must be submitted with a signed letter confirming your full time student status on your educational institution’s letterhead by your lecturer or student administrator. Seniors should supply a copy of their Senior Citizens Card. NOTE: The Student/Senior registration rate does not include the Conference dinner.

**Member Registration Fees
As per the 2010 AHPA Membership Benefits and Fees, members rates are available to Individual Members (not Corporate subscriptions).  The rate is available for the membership holder only and is not transferable.

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Membership Membership Type Membership Number
         
Indigenous Workshop
Sunday 10 April 2011, Cairns Convention Centre        
  AHPA Member Registration Fee $50.00    
  Non-Member Registration Fee $65.00    
         
Social Functions
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One ticket to each of the following functions is included in the full member and non-member Conference registration fee. Please confirm if you will be attending by checking the appropriate box.  To purchase additional tickets (or for day/student/senior registrations to purchase tickets) to any of the following functions please indicate the number required
Welcome Reception (Sunday 10 April 2011)      
Full Delegate I will attend  
Additional Tickets Number of additional tickets @ $45.00 each
(Ticket purchased here are for additional guests, day delegates and students)
Total

Conference Dinner (Tuesday 12 April 2011)

      
Full Delegate I will attendspace  
Additional Tickets Number of additional tickets @ $120.00 each
(Ticket purchased here are for additional guests, day delegates and students)

Total

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    GRAND TOTAL
     
Registration and Social Function Payment Details
Payment will follow please issue an invoice    
Please charge my credit card and forward an invoice    
  Card Number Expiry Date  
  Card Signatories Name      
  NOTE: Credit cards are not automatically charged when you submit this form. Cards will be processed within 5 working days of submission.
 
Accounts Contact


If you would like a copy of your invoice sent directly to your accounts section please provide an email and contact name below.
Accounts Contact: Title First Name Surname

Accounts Email

 
IF YOU DO NOT REQUIRE ACCOMMODATION
PROCEED TO THE CANCELLATION POLICY AT THE BOTTOM OF THE PAGE
 
Accommodation

To book your accommodation at the rates listed below complete this section of the registration form.

Bookings are subject to availability and should be made prior to Friday 11 March 2011.  All cancellations or amendments must be made in writing to Conference Co-ordinators and will be acknowledged by facsimile.  Please note your credit card details are required to guarantee your room. Neither Conference Co‑ordinators nor the hotel will make any charges against your credit card unless you fail to give 21 days notice in writing of your cancellation. Full payment of your account will be required at the time of your departure.
   
-
   
 
-SEBEL HOTEL CAIRNS Hotel Information  
STANDARD ROOM
 
-IL CENTRO HOTEL CAIRNS Hotel Information  
1 BEDROOM APARTMENT $155 per night
   
-PARK REGIS CITY QUAYS Hotel Information
HOTEL ROOM $145 per night
1 BEDROOM APARTMENT $165 per night
2 BEDROOM APARTMENT $215 per night
-PARK REGIS PIERMONDE Hotel Information  
2 BEDROOM APARTMENT $265 per night
3 BEDROOM APARTMENT $305 per night
 
-Please indicate your second and third choices of accommodation below should your first choice not be available.
-2nd Choice
-3rd Choice
 
Accommodation Reservations Details
I understand that neither Conference Co-ordinators or the hotel will make any charges against my card unless I fail to give at least 21 days notice in writing of my cancellation.  Cancellations or reductions to your booking made less than 21 days prior to your arrival will require payment in full unless the room(s) can be resold.  Full payment of the account will be required at the time of departure.
Date of Arrival dd/mm/yyyyDate of Departure dd/mm/yyyy
Estimated Time of Arrival Sharing with (if applicable)
Special Requirements
 
Accommodation Credit Card Information
Please use the credit card details provided above (to pay for my registration) to guarantee my accommodation
-Expiry
Card Number    Card Signatories Name
 
Cancellation Policy
I understand that by submitting this registration form I agree to the terms of the cancellation policy. Click here to view the cancellation policy.
   
  If your submission is successful a page will display
that thank-you for your registration and provides
further details. If the Thank-you page does not
display contact Conference Co-ordinators
on +61 2 6292 9000 or email ahpa@confco.com.au