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Class of 1974

Class of 1974 Reunion: 21-23 November 2014

REGISTRATION FORM

Please complete this form and return it with your payment, by not later than 17 OCTOBER 2014 and return to:

Joan Tuff, Alumni & Bequest Officer, UCT Faculty of Health Sciences, Anzio Road, Observatory, 7925.

Telephone: +27 (0)21406 6686, Fax: +27 (0)21650 5010 or +27 (0)86612 6390, Email:

Your details

Name:

Address:

Email Telephone/mobile numbers:

Your paymentSouth AfricanRands please

Tick your preferred payment method

1. cheque (payable to “UCT”)

2. direct (EFT) deposits

Bank:Standard Bank of South Africa, Rondebosch

Account name:UCT Sundries Account

Branch Code:025009

Account Number: 071503 854

Type of Account:Current

Reference: 1974surname120098 eg 1974adams120098

3. internet banking Same as direct deposits

Swift codeSBZAZAJJ (foreign payments) – please include bank charges with your payment

For payment methods 2 or 3, forward a copy of your deposit slip by fax or email to Joan Tuff

Fax +27 (0) 650 5010 or +27 (0)86612 6390 or Email:

4. credit card

Authority for payment by CREDIT CARD to the University of Cape Town

Please debit my American Express MasterCard Visa  Other:

Amount:

Card number

Last three digits on back:

Expiry date:

Today’s date:

Signature: …………………………………….

Programme

Fri, 21 Nov / 11h45 / Registration and Lunch, MAC Club, Medical School
13h15 / Tour of Medical School
15h00 / Tour of the Heart of Cape Town Museum, Groote Schuur Hospital
18h00 / Cocktail party – Institute of Infectious Disease & Molecular Medicine (IDM) building, Medical School Dress: Smart Casual
Sat, 22 Nov / 8h00-12h30 / Academic Meeting – Wolfson Pavilion Lecture Theatre, IDM Building
12h45 / Lunch – foyer, IDM Building
Afternoon / At leisure
18h30for 19h00 / Class photograph followed by Gala Dinner – Fuller Hall dining room
Dress: Jacket & Tie/Suit
Sun, 23 Nov / 06h30 & 8h30 / Medical 10 Race or mountain walk with Tim and Barry
10h30 / Guided tour of Kirstenbosch Gardens
12h00 / Family Picnic – Kirstenbosch Gardens

Costs

Date / Event / Cost / Number attending / Total
Friday,
21 November / Registration (obligatory; per class member only) / R700.00 per classmate / R700.00
Lunch – Mac Club / R120.00 per person
Heart of Cape Town Museum, Groote Schuur Hospital / R50.00 per person
Cocktail Party - Foyer, IDM Building / R140.00 per person
Saturday,
22 November / Academic meeting – Wolfson Pavilion, IDM Building / No charge
Light Lunch – Foyer, IDM Building / R120.00 per person
Gala Dinner – Fuller Hall dining room / R320.00 per person
Sunday,
23 November / *Guided Tour of Kirstenbosch Gardens / R45.00 per person
*Picnic - Kirstenbosch Gardens -
With ½ bottle of red or white wine (circle)
Without wine / R185.00 per person
R155.00 per person

* Entrance fee for your own account on the day

TOTAL PACKAGE (per class member):R1680.00

+ Spouse / PartnerR 980.00= R2660.00

Please note: In the event of a cancellation, a cancellation fee will be levied. Refunds may only be accommodated if confirmations for expenses such as catering, printing, photography, etc have not yet been made. Your understanding would be greatly appreciated.

Name tags

Classmate Partner

Name and SurnameName and Surname

Dietary preferences/allergies:

Walking disabilities:

Academic Meeting:

We need two more speakers - would you like to speak for 15 minutes of a topic of your choice?

If yes, title of your talk:

Audio-visual equipment required (specify):

The following class members have agreed to speak:

Ivan Schewitz / PectusExcavatum. The Nuss Procedure
Brian Warren / Surgical Practice in a Litigation-Prone Society
David Franklin / Life After Medicine?
Ted Sommerville / Learning from Teaching
Donald Miller / Investing is an Incurable Disease
Denis Brown / GP: SA vs GB
Haggis Black / Camera and Stethoscope – 40 Years in a Rural Practice
Peter Beresford / Establishing a culture of patient safety

Mountain Walk: Would you like to join Tim and Barry on a mountain walk?

Yes No If yes, number attending

OR

Medical 10 Race

Would you like to participate?

Yes No

Names of classmates who have indicated that they would like to attend thus far:

Beverley Adriaans, BrynneAscott-Evans, Peter Beresford, Haggis Black, Peter Bonafede, Denis Brown, Bruce Castle, Peter Chapman, Kathleen Commerford, Arnold Di Bella, Robin Emsley, David Franklin, Ian Gilbertson, RhodiahGool, Christopher Harrison, Patricia Hawke, FaikaJappie, Norman Marcus, Harold Marcus, StuartMeintjies, Donald Miller, Dirk Mouton, Tim Noakes, Andreas Obholzer, Olaf Opitz, Charles Palmer, ShafikParker, Barry Penn, Jeffrey Perlman, Paul Potter, Ivan Schewitz, Peter Schwartz, David Shlugman, Ted Sommerville, Rosalind Wainwright, Brian Warren, Bernard Werner.

Booklet forms received thus far - DEADLINE 17 OCTOBER (questionnaire on page 4)

Beverley Adriaans,BrynneAscott-Evans, Peter Beresford, Denis Brown, Peter Chapman, Kathleen Commerford, Arnold Di Bella, Robin Emsley, David Franklin, Ian Gilbertson, RhodiahGool, Christopher Harrison, Patricia Hawke, Donald Miller, Dirk Mouton, Andreas Obholzer, Olaf Opitz, Charles Palmer, Barry Penn, David Roy, Ivan Schewitz, Peter Schwartz, David Shlugman, Ted Sommerville, Manfred Teichler, Rosalind Wainwright, Brian Warren, Bernard Werner.

CLASS OF 1974

The ReunionBooklet – IF NOT ALREADY COMPLETED

Please complete this part whether you are attending the reunion or not.

Fill in the table below by TYPING in each answer. Be brief and include an ID size photograph as an attachment. Save the form as a word document, not a PDF, so that it can be copied and pasted into the booklet.

The completed form should beno longer than one page. Please note that you do not have to hit enter when filling in the form; the spacing will adjust automatically at the end of each line, therefore just click in each blank cell and type the individual answer. Please do not move or adjust the table or change the pre-set fonts.

Name
Home address
Code & country
Telephone (home)
Fax
Telephone (work)
Fax
Mobile
Email
Place of employment (if now retired, state last position held)
Field of Practice
Actual Job Description
Degrees (post grad)
What have you been doing since you graduated?
Tell us about your wife/partner, children and grandchildren
Hobbies, interests and sports
Achievements/Awards
Life’s memorable moments

Would you have any objection to this information being published in a UCT publication? YES NO

(we will not divulge your contact details)