Improving Healthcare International Convention 16-18 November 2015 Pullman Albert Park, Melbourne Register online at www.ihic.improve.org.au or return this completed form with payment to: IHIC 2015 Meeting Managers GPO Box 128 SYDNEY NSW 2001 AUSTRALIA Please complete one form for each registrant. All fees are quoted in Australian Dollars (AUD) and are inclusive of GST. A. DELEGATE CONTACT INFORMATION (please use block letters) TITLE (please circle) Dr Miss Mr Mrs Ms A/Prof Prof GIVEN NAME SURNAME ORGANISATION POSITION POSTAL ADDRESS CITY/SUBURB COUNTRY TELEPHONE MOBILE PHONE FAX EMAIL STATE POSTCODE PREFERRED NAME ON NAME BADGE RACGP MEMBERSHIP NUMBER (By providing your RACGP number the Improvement Foundation can apply for CPD points on your behalf) REGISTRATION PROMO CODE (if applicable) www.ihic.improve.org.au Improvement Foundation: 1800 771 522 B. REGISTRATION FEES Category 2 Day Registration Fee Endorsement Registration Fee (if applicable) Early Bird registration before 11 September 2015 □ $1,100.00 Standard Registration after 11 September 2015 □ $1,300.00 □ $880.00 □ $1040.00 B. Sub Total Registration Fee: A$ C. MASTERCLASSES Masterclasses Date Time (from – to) 16 November 2015 13:30 – 17:00 □ $250 16 November 2015 13:30 – 17:00 □ $250 16 November 2015 13:30 – 17:00 □ $250 Support for Leaders of LargeScale Change Mr Paul Plsek Fee A$ Utilising Research to Improve Patient Care Dr John Ovretveit Essentials of Optimising Systems for High Value Performance Dr Marjorie Godfrey and Dr Julie Johnson C. Sub-Total Pre Conference Workshops: A$ D. SOCIAL PROGRAM The Welcome Reception is included in your Delegate Registration Fee. If you require additional tickets please indicate this below: Event Welcome Reception Cost per ticket $65.00 Number of tickets required Total Cost The Gala Dinner is not included in the Delegate Registration Fee. If you would like to purchase tickets please indicate this below: Event Gala Dinner Cost per ticket $130.00 Number of tickets required Total Cost E. Sub-Total Additional Social Tickets: A$ www.ihic.improve.org.au Improvement Foundation: 1800 771 522 E. PHN Session (for PHN Staff only) The Improvement Foundation will be hosting a free session for PHN staff on Monday 16 November from 10.00am1.00pm. Please indicate if you will be attending: Yes | No F. ACCOMMODATION □ I do not require the Meeting Managers to book accommodation for me. I have made my own arrangements. □ Yes, I do require the Meeting managers to book accommodation on my behalf at the following. (A minimum one night’s deposit must be paid at time of booking.) Hotel Pullman Melbourne Albert Park Hotel Mercure Melbourne Albert Park Seasons Heritage Melbourne Room Type Room only rate per room per night Classic Room Single □ $215.00 Room and Breakfast rate per room per night N/A Classic Room Double □ $215.00 N/A Classic Twin Room □ $215.00 N/A Mercure Superior Room Single □ $155.00 N/A Mercure Superior Room Double □ $155.00 N/A Mercure Premium Room Twin □ $175.00 N/A One Bedroom Apartment □ $135.00 SGL Rate: Number of Nights Deposit □ $160.00 DBL/TWN Rate: □ $185.00 One Bedroom Apartment with Balcony □ $155.00 SGL Rate: □ $180.00 DBL/TWN Rate: □ $205.00 Two Bedroom Apartment □ $225.00 SGL Rate: N/A DBL/TWN Rate: □ $275.00 www.ihic.improve.org.au Improvement Foundation: 1800 771 522 Important - Please complete this section if you are booking accommodation through the Meeting Managers Arrival/Check in Date: Estimated Time of Arrival: Departure/Check out Date: Estimated Time of Departure: I wish to guarantee early check in by pre-booking and paying for the previous night on: / _ / Please be advised that accommodation venues require all names of those staying on the premises for workplace, health and safety purposes. I will be sharing this room with Special Requirements e.g. smoking/ non smoking room (subject to availability) D. Sub-Total Accommodation: A$ NOTE: LATE ARRIVALS / NON ARRIVALS Please indicate when you register, or notify the Convention Managers in writing, if you will arrive at your hotel after 18:00 hours. Failure to do so may result in your room being treated as a no-show and being released. www.ihic.improve.org.au Improvement Foundation: 1800 771 522 G. SPECIAL DIETARY REQUIREMENTS Please specify any special dietary requirements. Every attempt will be made to meet your requirements; however this may not be possible in every case. □ Gluten Free □ Lactose Intolerant □ Allergy to Nuts □ Halal □ Vegan □ Kosher □ Allergy to Shellfish □ Vegetarian Other G. MATERIAL DISTRIBUTION □ YES – I consent to receiving information from Arinex Pty Limited or other Organisations on related products or services from time to time. □ NO – I do not consent H. DELEGATE LIST □ YES – please include my details as given in this form (and any subsequent amendment) in the Delegate List produced for the Meeting which will be supplied to organising bodies, sponsors, exhibitors and all delegates attending the Meeting. □ NO - please do not include my details in the Delegate List. www.ihic.improve.org.au Improvement Foundation: 1800 771 522 I. DELEGATE PROFILE 1. Where did you hear about the Convention? Advertisement APCC update E-mail Facebook IF eNews IF website Linkedin qiCommunity Update Twitter Sponsor Other (Please state ) 2. What sector or specialty group do you represent? Aboriginal and Torres Strait Islander Sector Allied Health Sector Community Organisation Consumer Group/Representative Disability Sector Education Government Health Specialist Hospital Not for Profit Organisation Primary Care Heath Service Technology Other (Please specify): www.ihic.improve.org.au Improvement Foundation: 1800 771 522 J. PAYMENT AND CONDITIONS Section B Section C Registration Fee Pre Conference Workshops $ $ Section D Accommodation Section E Social Program TOTAL FEE PAYABLE AND ENCLOSED $ $ NOTE: Registrations will not be processed or confirmed until payment in full is received. By completing this form you accept all terms and conditions as outlined on the Convention website. Please select your preferred payment option below: □ Cheque: please find enclosed cheque/money order payable to Arinex Pty Limited for IHIC Convention 2015 □ Credit Card: please charge the total amount above to the following credit card Mastercard Visa Diners Club AMEX Please note all transactions by credit card will appear on your statement as payment to: Conference by Arinex Pty Limited. Credit card number / / / / / / / / / / / / / / / / Validation Code: Expiry Date: / Name on card: Billing Address: Signature: Date: / / NOTE: 1. Your registration will not be processed or confirmed if payment is not forwarded with this form. 2. Confirmation of your registration will be sent to you within 10 working days from receipt of your registration form. 3. Earlybird registrations rates – form must be mailed by 11 September 2015. For further registration terms and conditions please visit www.ihic.improve.org.au www.ihic.improve.org.au Improvement Foundation: 1800 771 522
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