Conference Registration 36th Priorities in Perinatal Care Conference will take place at Mpekweni Beach Resort from 7-10 March 2017. Conference Registration - 2017 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 20 February 2016, 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*NoneVegetarianHalaal - R825Other - please specify belowHalaal Meals - R825 one-off fee for full delegates Family/accompanying person: Please contact [email protected] for rates for non-conference attending people.Full Delegate - Halaal Surcharge (ignore if zero value)R825 surcharge applies for full delegatesOther/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 Title(s)Please specify the title and whether they are Oral or Poster based presentationsScientific 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 East LondonFlying to Port ElizabethPlease 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 7 March 2017 10 March 2017 East London R750 (single or return, min 41 people) Departure from airport: 12h30 Estimated travel time 2+ hours. Departure from venue: 13h00 Estimated travel time 2+ hours. Return flights should depart after 16h30 at the earliest Port Elizabeth R950 (single or return, min 41 people) Departure from airport: 12h00 Estimated travel time 3+ hours. Departure from venue: 13h00 Estimated travel time 3+ hours. Return flights should depart after 17h30 at the earliest Airport bus leaves at specified time only (one transfer per airport), please book your flights accordingly especially your return flights on 10 March or arrange your own transport to and from the venue. No lunch at the venue on 7 March so please eat/buy at the airport. Conference starts at 15h30 with tea on 7/3 and ends after lunch at 13h00 on 10/3Inbound flightFlight details for your arrival on 7 March 2017Flight Number*Arrival Time : HH MM Time in 24 hour format pleaseOutbound flightFlight details for your departure on 10 March 2017Flight Number*Departure Time* : HH MM Time in 24 hour format pleaseAirport TransfersBus to/from airport*No bus transport requiredEast London (Single or return - same price) - R750Port Elizabeth (Single or return - same price) - R950Do you require bus transport between your inbound and outbound airport and the conference venue? R750.00 Single or return from East London R950.00 Single or return from Port ElizabethRegistration and AccommodationCheck-in time: 14h00, registration starts at 14h00 and conference starts at 16h30. Tuesday lunch not included in conference rate. Family/accompanying person: Please contact [email protected] for rates for non-conference attending people.Accommodation Option*Single apartment room - R7400 per personSingle hotel room - R7400 per personSharing apartment room - two sharing apartment room and bathroom - R6100 per personSharing hotel 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 with*Please supply the name and surname of the person with whom you would prefer to share a 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 1R2220 2R2480 3R2740 4R3000 Day(s) AttendingHow many days will you be attending in total?*Days Attending - One - R2220Days Attending - Two - R2480Days Attending - Three - R2740Days Attending - All Four - R3000Registration 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*NoneVegetarianHalaal - R115 per dayOther - please specify belowHalaal Meals - R115 per day surcharge. Applies to lunch and teas per day attending separate from any Halaal meals chosen Family/accompanying person: Please contact [email protected] for rates for non-conference attending people.Day Delegate - Halaal Surcharge (ignore if zero value)R115 surcharge applies for lunch and tea per day attending separate from any Halaal meals chosenOther/additional dietary requirementsDays attending and meal choicesPlease indicate on which date(s) you may be attending and will require breakfast (R155 per person) or dinner including soft drink (R195 per person) or both for R350. Halaal meals are charged at R235 per person for breakfast, R275 for dinner including soft drink, or both for R510.7th March 20177th March 2017 - Attending conference7th March 2017 - Attendance including dinner7th March 2017 - Not attending on this day8th March 20168th March 2017 - Attending conference8th March 2017 - Attendance including breakfast8th March 2017 - Attendance including dinner8th March 2017 - Attendance including breakfast and dinner8th March 2017 - Not attending on this day9th March 20169th March 2017 - Attending conference9th March 2017 - Attendance including breakfast9th March 2017 - Attendance including dinner9th March 2017 - Attendance including breakfast and dinner9th March 2017 - Not attending on this day10th March 201610th March 2017 - Attending conference10th March 2017 - Attendance including breakfast10th March 2017 - 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 EmailThis field is for validation purposes and should be left unchanged. 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