Mulligan Concepts Course Part B (lumbar spine, sacroiliac joints and lower quartile) REGISTRATION FORM Date: Venue: 18th and 19th April, 2015 School of Physiotherapy Room 103 Dunedin Name: _______________________________________________________________________________ Address: _______________________________________________________________________________ _______________________________________________________________________________ Telephone: (H)___________________ (W)___________________ (mobile)___________________ Email: _______________________________________________________________________________ Dietary Requirements: _______ I consent to my name being put on the attendee list for circulation to other attendees Yes / No Registration Fee: Otago Branch Member PNZ Member Non-PNZ Member $400 $480 $600 Payment: Cheque payable to “Physiotherapy New Zealand” - post with Registration Form Internet banking to 01 0527 0006484 00 (incl your name in Ref field) AND Fax this form Credit Card - post/fax Registration Form  Card number:  Expiry date: 3 digit code (back of card)  Name on card:  Signature:  Amount Paid: Notes: - Registration includes the course manual, morning and afternoon teas and lunches. Registration is secured by payment on a first come first served basis and is strictly limited to 18 participants. - The organisers reserve the right to cancel the course if insufficient registrations received by 30th March 2015. Cancellation Policy: Written cancellations will be accepted up to the 27th of March 2015. Refunds (less a $50 administration fee) will be given. No refunds will be given for cancellations received within two weeks prior to the course commencement date. Positions will be limited to the first 18 paid up. Signature: I have read the notes and conditions above, and understand and agree to the cancellation and refund clauses: Signed: Date: Physiotherapy New Zealand, PO Box 27 386, Marion Square, Wellington 6141 [email protected] Fax: 04 801 5571 Ph 04 801 6500