Public Health 2004 conference
Challenging health inequalities;
Forging progressive partnerships for public health

Registration form

Early registration deadline - 30 April 2004
Late/On site registration: 6 June 2004
Cancellation deadline: 28 May 2004

 

Please complete the form below (one per delegate) and submit electronically or
fax it to Nadine van Rensburg at +27 21 938 0395
Required fields are marked with an *

Personal details
*Title
*First name
*Surname
*Company/Organisation
*Address
*City  
State/Province  
*Country  
*Postal code/zip  
*Work telephone:   Code Number
Fax number:  Code Number
*E-mail address
Other preferences
None:     Kosher:     Halaal: OR
Other:
Are you disabled?   No:   Yes:
Accommodation and tranfer

Please complete the separate transport and accommodation form on the home page

Do you require courtesy airport transfer?:
Yes:   No:

Do you require accommodation?
Yes:   No:

Scientific programme                         Check currency here

Local registration
Late/on site registration (R1700): Deadline: 6 June 2004;
Day Registration (R850):
  
Overseas registration (low income countries: Latin America, Asia & Africa)
Late/on site registration (USD 250): Deadline: 6 June 2004
Day Registration (USD 125):
   
Overseas registration (high income countries: N. America, Europe, Australia & New Zealand)
Late/on site registration (USD 300): Deadline: 6 June 2004
Day Registration (USD 150):

Student registration
Late/on site registration (R1200): Deadline: 6 June 2004;
Day Registration (R600):

*Subtotal: R

Workshops

Introduction to motivational interviewing, R300 (Date: 5 June 2004, Time: 08:30 - 16:00)
Practicing evidence-based health care, R300 (Date: 8 June 2004, Time: 08:30 -16:00)
District health information software, R300 ( Date: 8 June 2004, Time: 08:30 -16:00)
Making sense of mortality data, R300 (Date 8 June 2004, Time: 08:30 -16:00)
Enviromental health, R250 (Date: 8 June 2004, Time: 09:00 - 12:00)
Nutrition, R250 (Date: 8 June 2004, Time: 09:00 - 12:00)

*Subtotal: R

Social events
Conference barbeque
Local delegates (R180)
Overseas delegates (USD 30)		   
R
*Subtotals:
 R
*Total payment:
R
Methods of payment
Payments can be made by personal cheque, credit card or bank/wire transfer. Please clearly indicate the person’s name on the deposit slip or your registration no (this is received on receipt of your registration form) in order for deposits to be linked to your registration. A copy of the deposit slip must be faxed to Nadine van Rensburg at +27 21 938 0395.

Bank/wire transfers and cheques must be made payable to:

South African Medical Research Council
ABSA Bank
Bank Acc No 906 475 8975
Branch Code: 632 005
*Payment submission:               
Cheque:       OR Bank/wire transfer:      OR Credit card:
Required: Please fax your deposit slip of your payment to Nadine van Rensburg at +27 21 938 0395.
Cancellation and refund policy

Cancellations must be sent in writing to:

Event Office (Public Health 2004)
Medical Research Council
PO Box 19070, Tygerberg, 7505
Cape Town, South Africa

For cancellation before 28 May 2004, a cancellation charge amounting to 20% of the registration fee will be deducted from the refund. No refund for cancellations will be granted for any reason after 28 May 2004.

If you need courtesy transport from the airport, please complete a separate transport form.


ORGANISED BY MRC EVENT OFFICE