Perinatal Priorities – Conference Registration Conference Registration - Perinatal Priorities - 2018 Step 1 of 6 0% Delegate Type*Full DelegateDay DelegatePlease note that fields marked with a red asterisk are mandatory entry/selection items and must be completed for your registration to be successful. Upon completion of your registration you will receive an e-mail confirming your information. An invoice for your registration will accompany the e-mail as a PDF attachment. Registration closes on 24 February 2018, or when the conference is full, whichever happens first. Personal InformationTitle*MsMrsMrDrProfName* First Last Name on badgeName to appear on badge - Please specify your first name or name used and surname ONLY.Gender*MaleFemaleDietary Requirements - Full DelegatesNOTE: All meals are served as a buffet and you will be able to select the foods you eat. Please indicate specific food preferences, e.g. Halaal, vegetarian or other, below. Kindly complete your own registration form and list your dietary requirements (if applicable). Dietary Requirements - Full Delegates*Dietary Requirements - NoneDietary Requirements - VegetarianDietary Requirements - Halaal - R1870 one-off feeDietary Requirements - Other - please specify belowHalaal Meals - R1870 one-off fee for full delegates Family/accompanying person: Please contact firstname.lastname@example.org for rates for non-conference attending people.Other/additional dietary requirementsContact InformationPlease ensure that the contact details given below are accurate to ensure that the conference organisers can get in touch with you should the need arise.Cell Number*Phone Number*Fax NumberEmail Address* Institution*VAT numberEnter the paying institution VAT number if required for invoicing.Address*Please supply a full postal address, including the postal code, as required for invoicing purposes. Postal Address City County / State / Province ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe PresentationsPresentation TitleDo you require a bursary application?*NoYesBursaries are for presenters only. Only one presenter per abstract will be considered for a bursary.Scientific program*NoYesIf you don’t have access to the Internet, do you want us to send you a scientific programme when it has been finalised (only for people providing valid fax number/e-mail address)Workshops information*NoYesAre you interested in receiving additional information regarding the workshops? (full delegates only)CPD CertificationDelegate badges will be scanned daily at registration desk CPD/attendance purposes. CPD certificates will be printed with the badge name specified on this registration form.CPD Certificate*NoYesI require a CPD/attendance certificate (will be printed with name as supplied on this registration form) will be e-mailed to you, please make sure that you have supplied a valid e-mail address and registration number. No registration number provided below = no CPD certificate.MP/relevant number* Note: CPD certificates can only be provided for delegates who provide the relevant registration number. Will you be flying to the conference?*Not FlyingFlying to Durban (KSI)Flying to Johannesburg (ORT)Please indicate whether you will be flying or not, so we may capture additional detailsFlying DelegatesFlight details and airport bus details are only required for delegates flying in. Please take note: Take careful note of the bus departure times listed below. Ensure that your flight arrangements (where applicable) allow sufficient time for you to meet the bus prior to departure. Transfer from & to 13 March 2018 16 March 2018 OR Tambo International (Johannesburg) R1300 per person (single or return) Departure from airport: 10h00 Estimated travel time 4-5+ hours. Departure from venue: 13h00 Estimated travel time 4-5+ hours. King Shaka International (Durban) R950 (single or return, min 41 people) Departure from airport: 11h00 Estimated travel time 3-4+ hours. Departure from venue: 13h00 Estimated travel time 3-4+ hours. Airport bus leaves at specified time only (one transfer per airport), please book your flights accordingly especially your return flights on 16 March or arrange your own transport to and from the venue. No lunch at the venue on 13 March so please eat/buy at the airport. Conference starts at 15h30 with tea on 13/3 and ends after lunch at 13h00 on 16/3Inbound flightFlight details for your arrival on 13 March 2018Flight Number*Please mark as "UNKNOWN" or "PENDING" if you have not booked your flights yet.Arrival Time : HH MM Time in 24 hour format pleaseOutbound flightFlight details for your departure on 16 March 2018Flight Number*Please mark as "UNKNOWN" or "PENDING" if you have not booked your flights yet.Departure Time : HH MM Time in 24 hour format pleaseAirport TransfersBus to/from airport*No bus transport requiredJohannesburg (Single or return - same price) - R1300Durban (Single or return - same price) - R950Do you require bus transport between your inbound and outbound airport and the conference venue? R1300.00 Single or return from Johannesburg R950.00 Single or return from DurbanRegistration and AccommodationCheck-in time: 15h00, registration starts at 14h00 and conference starts at 16h30. Family/accompanying person: Please contact email@example.com for rates for non-conference attending people.Accommodation Option*Single hotel room - R7500 per personSingle chalet room (Sharing chalet with two other people) - R7500 per personSharing hotel room - two sharing hotel room and bathroom - R6100 per personSharing two-bedroom hotel family room - two sharing bathroom - R6100 per personSharing chalet room - two sharing bedroom and bathroom - R6100 per personNote: The rates shown include both conference registration and accommodation fees and are not applicable to non-conference attending people.Sharing chalet room with*Please supply the name and surname of the person with whom you would prefer to share the chalet room.Sharing chalet with first person*Please supply the name and surname of the first person with whom you would prefer to share the chalet.Sharing chalet with second person*Please supply the name and surname of the second person with whom you would prefer to share the chalet.Sharing hotel room with*Please supply the name and surname of the person with whom you would prefer to share the hotel room.Sharing family hotel room with*Please supply the name and surname of the person with whom you would prefer to share the family room.Important NoteAn administration fee of R250 will be charged on any refunds - please confirm amounts before making payment. Delegates will not be registered on receipt of orders. An invoice will be issued when an order is received and the delegate(s) will be registered when the invoice is paid. You may deposit cheques directly into the bank account. Online credit card facilities available on Priorities website. Completed registration forms and full payment secure your place at the conference. Day Delegate OptionsRegistration and AttendancePlease indicate below which date(s) you will be attending the conference as a Day Delegate. Note that day delegate registration fees quoted below include lunch and tea(s). Day Delegate registration fees Number of daysRegistration fee 1R2700 2R3300 3R3900 4R4500 Day(s) AttendingHow many days will you be attending in total?*Days Attending - One - R2700Days Attending - Two - R3300Days Attending - Three - R3900Days Attending - All Four - R4500Registration and attendance as day delegate (including lunch & tea(s). Please specify attendance dates and food/drink choices belowDietary Requirements - Day DelegatesNOTE: All meals are served as a buffet and you will be able to select the foods you eat. Please indicate specific food preferences, e.g. Halaal, vegetarian or other, below. Kindly complete your own registration form and list your dietary requirements (if applicable). Dietary Requirements - Day Delegates*Dietary Requirements - NoneDietary Requirements - VegetarianDietary Requirements - Halaal - R550 per dayDietary Requirements - Other - please specify belowHalaal Meals - R550 per day surcharge. Applies to lunch and teas per day attending separate from any Halaal meals chosen Family/accompanying person: Please contact firstname.lastname@example.org for rates for non-conference attending people.Other/additional dietary requirementsDays attending and meal choicesPlease indicate on which date(s) you may be attending and will require breakfast (R145 per person) or dinner including soft drink (R265 per person) or both for R410. Halaal meals are charged at R280 per person for breakfast, R380 for dinner including soft drink, or both for R660.13th March 201813th March 2018 - Attending conference13th March 2018 - Attendance including dinner13th March 2018 - Not attending on this day14th March 201814th March 2018 - Attending conference14th March 2018 - Attendance including breakfast14th March 2018 - Attendance including dinner14th March 2018 - Attendance including breakfast and dinner14th March 2018 - Not attending on this day15th March 201815th March 2018 - Attending conference15th March 2018 - Attendance including breakfast15th March 2018 - Attendance including dinner15th March 2018 - Attendance including breakfast and dinner15th March 2018 - Not attending on this day16th March 201816th March 2018 - Attending conference16th March 2018 - Attendance including breakfast16th March 2018 - Not attending on this dayImportant NoteAn administration fee of R250 will be charged on any refunds - please confirm amounts before making payment. Delegates will not be registered on receipt of orders. An invoice will be issued when an order is received and the delegate(s) will be registered when the invoice is paid. You may deposit cheques directly into the bank account. Online credit card facilities available on Priorities website. Completed registration forms and full payment secure your place at the conference. Terms and ConditionsAny refunds (duplicate payments, incorrect amount paid, cancellations, etc) will all incur a R250 admin fee. By checking the field below, completing and submitting this form, I indicate that I have read the information in the registration pack and accept the terms set out in the registration pack (especially with reference to cancellations and refunds).I accept the terms and conditions*Yes, I accept the terms and conditions aboveCheck the box to indicate your acceptance of the terms and conditions.Total due R0.00 PhoneThis field is for validation purposes and should be left unchanged.