/ ONEMDA WRITERS RETREAT
7 – 8 April 2016
REGISTRATION FORM
Date:
This form enables you to:
ü  register to attend the Onemda Writers Retreat 7 – 8 April 2016
ü  pay for Retreat either by cheque, EFT or credit card
Please complete and return this form via email to:
Jasmin Boys
Onemda VicHealth Koori Health Unit
Centre for Health and Society, Melbourne School of Population and Global Health
The University of Melbourne Level 4, Bouverie Street, Carlton VIC, 3010 Australia / Important notes
ü  all prices quoted are in Australian Dollars (AUD) and inclusive of Goods and Services Tax (GST).
ü  please send all pages to Jasmin Boys at .
ü  please keep a photocopy for your record. One form per person.
ü  Please leave payment details blank if it doesn’t apply to you.
Contact details
Mr Ms Mrs Miss Dr Prof. / Other (please specify)
Last name / First name
Organisation
Position
Address
Suburb/Town
State / Country / Postcode
Work phone / (03) / Work fax / ( ) / Mobile
Email
Name badge: Please indicate correct details for your name badge, if different from above:
First name / Last name / Organisation
Role at conference: Please indicate what your role at the Writers Retreat will be. Please select only one:
Delegate / Invited speaker / Sponsor
Registration
Registration type / Standard rate
Employed / $400:00
Student / Unemployed / $200:00
TOTAL / AUD / AUD

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MEALS
All meals are included and will be served in the Mt Eliza Dining room and Breakout rooms
Dietary requirements
Delegate
Vegetarian / Vegan / Gluten free / Halal
I have an allergy to

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Accommodation Booking details
No. of occupants per room / If greater occupancy per room is required than that indicated by bed sizes, extra fees may apply.
Arrival date / 7 April 2016 / Arrival time / AM /
Departure date / 8 April 2016 / Departure time / PM / Check out approximately 9:00am
Special accommodation requirements
How did you find out about the Onemda Writers’ Retreat
Colleague told me / Direct email notification / Journal advertisement / website
Received information in the mail / Website search / Workplace notice board / Other e-newsletter – please specify
Special requirements for the conference
Please list any special requirements. / Wheelchair access / Other please specify:
PAYMENT AUTHORISATION
I hereby authorise Melbourne Business School to debit payment:
The card holder authorises Melbourne Business School to charge for the forthcoming Writers Retreat.
Name:
Company Name:
Date:
Deposit Amount: $
Address:
Email:
Mt Eliza Executive Education ABN 80 007 268 233 | Kunyung Road Mt Eliza Victoria 3930 Australia
Tel: +61 3 9215 1100 Fax: + 61 3 9787 5139 Web: www.mbs.edu/mteliza
PAYMENT SUMMARY
Employed / $
Student / Unemployed / $
TOTAL / $
METHOD OF PAYMENT
All amounts on this form are in Australian dollars (AUD$) and include 10% Goods and Services Tax (GST).
Credit card / Visa MasterCard Diners American Express.
Card holder name / CCV
Card number / Expiry date / /
Signature

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