bottom
top3
top
registration form
Australian Health Promotion Association ABN 44 373 080 790
By submitting this form you agree to the terms of the cancellation policy set out in the conference information brochure.
All prices quoted are in Australian Dollars and are inclusive of GST

The data in this form is not recorded until the SUBMIT button is pushed. The SUBMIT button is at the bottom of this form. 

NOTE: You will receive written confirmation of your registration (which will also be your invoice) within seven days from Conference Co-ordinators.  If you do not receive written confirmation please contact Conference Co-ordinators on +61 (0)2 6292 9000 or via email at apha@confco.com.au.
 
 
 

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  
 
Title Mr, Ms, Dr, Prof
 First Name  
  Surname  
 
Position
 
 
Organisation
 
 

Mailing Address

 
 

 

  
 
Suburb
State Postcode  
  Country  
  Telephone Fax  
 
Mobile
 E-mail  
 
Name for Badge
  
     
  Special Requirements eg Diet:  
 
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 My abstract code as quoted in my confirmation letter is
 
  Full Registration Fees          
 

Early Bird (Payment received by 24 March 2009)

    
    Member Registration Fees
$675.00
 CLOSED    
    Non Member Registration Fees
$775.00

CLOSED

    
    Full-Time Student Registration*
$375.00
 CLOSED    
  Late (Payment received after 24 March 2009)        
    Member Registration Fees
$725.00
      
    Non Member Registration Fees
$825.00
      
    Full-Time Student Registration*
$425.00
      
  Day Registration Fees
        
  Early Bird (Payment received by 24 March 2009)          
    Member Early
$275.00
 CLOSED    
    Non Member Early
$350.00
 CLOSED    
    Student Early
$135.00
 CLOSED    
  Late (payment received after 24 March 2009)        
    Member Late
$325.00
      
    Non Member Late
$400.00
      
    Student Late
$185.00
      
    Indicate which day you will be attending
 
Total
 
 

*Full Time Students must provide evidence from their educational institution of their full-time status

      
  ATSI Workshop (Sunday 17 May 2009)          
    Not Attending        
    Member Registration Fees
$50.00
      
    Non Member Registration Fees
$60.00
  
Total
 
  Membership Membership Number        
             
  Included Social Functions          
  One ticket to each of the following functions is included in the full Congress registration fee. Please confirm if you will be attending by checking the appropriate box.  To purchase additional tickets (or for day/student registrations to purchase tickets) to any of the following functions please indicate the number required    
  Welcome Reception (Sunday 17 May 2009)        
  Full Delegate I will attend Number of additional tickets @ $45.00 each
Total
 
 

Conference Dinner (Tuesday 19 May 2009)

        
  Full Delegate I will attend Number of additional tickets @ $120.00 each
Total
 
  Additional Social Functions          
  Tickets to the following are not included in registration and must be purchased.  Numbers are limited.    
  Dinner with the Stars (Monday 18 May 2009) Number of tickets @ $60 each
Total
 
           
     
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 Holders Name        
    NOTE: Credit cards are not automatically charged when you submit this form. Cards will be processed within 5 working days of submission.  
       
 
IF YOU DO NOT REQUIRE ACCOMMODATION
PROCEED TO THE CANCELLATION POLICY AND SUBMIT BUTTON AT THE BOTTOM OF THE PAGE
  
     
  Accommodation  
 

To book your accommodation at the rates listed below complete the appropriate section of the registration form. Bookings are subject to availability and should be made prior to Friday 3 April 2009.

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 at least 21 days notice in writing of your cancellation or if less than 21 days prior to arrival your booking is reduced or cancelled in which case full payment will be required unless the room(s) can be resold. Full payment of your account will be required at the time of your departure.  NOTE: Some hotels may do a pre-authorisation to ensure the validity of the card supplied.

Rates quoted are per room per night GST inclusive and DO NOT include breakfast.

 
 
Not Required
           
 
Parmelia Hilton		   Date of Arrival  
  Standard $305 per night Single Twin Double    
 
Medina Grand 		        Date of Departure  
  Studio $270 per night SOLD OUT    
  1 Bedroom Apt $300 per night Single Twin Double   Sharing with (if applicable)  
 
Rydges Perth		    
  Superior $279 per night Twin Double   Estimated Time of Arrival  
  King Executive $328 per night Single Twin Double    
 
Sommerset St Georges Terrace Perth		   Special Requirements  
  Deluxe $210 per night    
  Executive $235 per night      
 
The Marque Hotel		    
  Standard $242.00 per night Single   Please indicate your second and third choice of accommodation below should your first choice not be available .  
             
  Aarons Hotel         Second Choice  
  Standard $145 per night Single    
            Third Choice  
  Please note credit card details are required to guarantee your room.  
       
  I understand all cancellations or amendments must be made in writing to Conference Co-ordinators and will be acknowledged in writing. Neither Conference Co-ordinators nor the hotel will make any charges against your credit card unless you fail to give at least 21 days notice in writing of your cancellation or if less than 21 days prior to arrival your booking is reduced or cancelled in which case full payment will be required unless the room(s) can be resold. Full payment of your account will be required at the time of your departure.  NOTE: Some hotels may do a pre-authorisation to ensure the validity of the card supplied.  
  Please use the credit card details provided above to guarantee my accommodation  
   

Card Type

 
    Card Number Expiry Date  
    Card Holders 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 thanks-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