Conference Registration Registration for the 38th Priorities in Perinatal Care Conference – Hartenbos, Western Cape, 12- 15 March 2019 Delegate InformationSurname*Title*Initials*First name and surname* First Last This will be used for your name badge. Corrections cannot be made afterwardsApplicable number for attendance and CPD certificateComplete the applicable numberMP numberSANC numberInstitutionCell number*for SMS communicationEmail address or Fax number*If no email, please provide fax numberPresentations: Abstract submissions deadline 8 February 2019If you will not be submitting an abstract, please skip, otherwise check applicable option. Online form submissions will be available as usual.Abstract typePosterOral PresentationPresentation titleDo you want to apply for a bursary?YesNoPlease tick the applicable option. If yes, the guidelines will be e-mailed to you (only presenters)Flying delegates(Only mini-buses from George airport available)Will you need bus transfers from George airport?YesNoCost R375. Please forward your flight details at your earliest convenience so that the transfer can be arranged.AttendanceWill you be a full or day delegate?*Full Delegate (not sharing)Full Delegate (sharing)Day DelegateFull Delegate Pricing Single accommodation: R6750 Sharing accommodation: R6150 If you want to bring a non-conference attending person with you, please contact us at email@example.com for a breakdown of rates (accompanying person)I plan to share with*Day Delegate attendance Tue 12 March 2019 Wed 13 March 2019 Thu 14 March 2019 Fri 15 March 2019 Includes teas and lunch. (You will not be staying at the conference venue, meaning breakfast and dinner is excluded) Registration and attendance for 1 day as day delegate R2375 OR Registration and attendance for 2 days as day delegate R2950 OR Registration and attendance for 3 days as day delegate R3525 OR Registration and attendance for 4 days as day delegate R4100 Dinner additional charge for day delegates (R200 per person per day including soft drink)Day Delegates - Add breakfast and dinner?*Dinner required - please invoiceNot requiredRate excludes breakfast and dinner - if dinner is required, please indicate for invoice purposes - R200 per dayFood preference*NoneVegetarianHalaalHalaal incurs a surcharge of R1800 per full delegate (If you are a day delegate we will provide you with a breakdown)I need an invoice*YesNoWe are no longer sending out automated invoices. If you require an invoice one will be generated for you.Invoice name and address*Provide the full name and address that we should make the invoice out toI'm not sure what to pay, please send me a breakdown of the costs*YesNoBank DetailsAccount Name: Priorities in Perinatal Care Bank & Branch: ABSA, Centurion Cheque Account Number: 4051977046 Branch Code: 630445 SWIFT Code: ABSAZAJJ The Priorities in Perinatal Care Association is registered as a public benefit organisation (PBO no: 930023314), registered non-profit organisation (148-351NPO) – tax reference number: 9022/514/17/9 and is not registered for VAT.NameThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.