Registration form for 2016/17 ASNG Membership & attendance for the 25thMay Study DayManukau Super Clinic, Browns Road, Manukau

Each individual nurse please print and complete the registration sections below and forward them to Juliet David (see details below).

Regardless of whether you are attending the study day or not, can you please return all forms with payment by Wednesday 18thMay 2016.

Name
NCNZ APC No: / NCNZ APC Expiry Date:
Nursing
Qualification: / PG Qual
(Youth Health only)
School: / Cluster:
School Address:
School ph no: / Extension:
School Email:
Home ph: / Mobile:
Home Email: / (only if email to go to this address)

Membership (May 2016 – April 2017) and Study Day Registration:

(Choose from 1 of the following 3 options) /  / Amount
2016/17 Membership fee and attending May Study Day / $80.00
2016/17Membership fee only (not attending Study Day) / $40.00
Non-member attending study day / $90.00
Select 1 ‘Eat My Lunch’ Option (circle) / Standard
‘lunch box’ / Gluten free
‘lunch box’ / Vegetarian
‘lunch box’
Payment Amount: $______
Payment Options:
Direct Debit Account: ASNG Society Account - 12-3041-0283768-00
Please enter initials/name of nurse in reference field and name of school in code field.
NB: A copy of the form must be sent to Juliet David for administration purposes.
Make cheques payable to: Auckland School Nurses Group
c/o Juliet David
35 Onslow Ave
Epsom
Auckland 1023

Wednesday 25thMay 2016

8.30 am to 3.15 pm

Venue: Manukau Super Clinic – Conference Room 1

Browns Road, Manukau

Time / Session
8.30am / 8.45am / Registration
8.45am / 9.00am / Welcome & introductions
9.00am / 10.00am / Annual General Meeting
10.00am / 10.30am / Morning Tea (provided)
10.30am / 11.00am / Challenges for Refugee Young People – Youth Panel
11.00am / 11.30pm / Refugee Case Study – Marie Shepherd (RN)
11.30am / 12.30pm / SHAKTI
12.30pm / 1.15pm / Lunch (provided)
1.15pm / 2.15pm / Asian mental health, key stressors. Patrick Au (RN)
2.15pm / 3.00pm / Mental Health Assessment tools. Rudy Bakker (RN)
3.00pm / 3.15pm / Housekeeping

Programme Changes
This is final programme as at 11 April 2016. The Executive Committee reserves the right to alter or delete items from the program without notice.

Registration and Payment
Please complete the Registration form (page 1) and forward with your appropriate payment by Wednesday18thMay to Juliet David

Nominations for Committee and Office
Each cluster requires a representative on the Executive Committee; please discuss and nominate a candidate within your cluster. The Executive Committee also requires nominations for the positions of President, Treasurer and Secretary.

Certificate of Attendance
Certificate of Attendance needs to accurately reflect the hours of professional development for your portfolio. If you are unable to attend for the full day (5hrs) your certificate of attendance will be manually amended.

No refunds for cancellations after Friday 20thMay, 1200 noon (must be a phone call to an Executive Committee member).

Please note:

All clusters must have a representative on the ASNG Executive Committee.

Please discuss at your cluster meetings and nominate your representative, ensuring they consent to and have signed the nomination form.

2016/17 Auckland School Nurse’s Group Cluster Representative and Executive Committee Members.

Cluster Representative

Cluster nominate for Executive Committee
Cluster
Name of nominee
Nominate
Signature of nominator
Signature of nominee
I consent to my nomination

Executive Committee

Name and school
I
Name of nominee
Nominate
Position of Office eg President, Treasurer, Secretary
as a candidate for the office of
Signature of nominator
Signature of nominee
I consent to my nomination

ASNG 2016 / 2017 Membership Study Day Registration FormPage 1 of 3