2016 CONFERENCE REGISTRATION FORM

YOUR PERSONAL INFORMATION

First Name
Surname
Address
Suburb
Postcode
State
Country
Phone (day)
Email

ADDITIONAL DELEGATES – FAMILY MEMBERS & CARERS

First Name
Surname
Phone
Email
First Name
Surname
Phone
Email
First Name
Surname
Phone
Email

STATUS – Please tick the relevant statement:

☐ I am a sufferer

☐ I am a carer

☐ I am a medical professional FIELD:

DIAGNOSIS – Please tick your diagnosis or that of the person you care for, if applicable.

☐ Cutaneous Mastocytosis

☐ Systemic Mastocytosis

☐ Aggressive Systemic Mastocytosis

☐ Mast Cell Activation Disorder (MCAD)

EMERGENCY CONTACT AND DETAILS

Name
Mobile
Relationship
Do we need to contact your GP or specialist (info below in research)? / ☐ Yes / ☐ No
Do you suffer from Anaphylaxis? ☐ Yes ☐ No
Please list your allergies:

Is there any other information we need to know about your health and possible emergency situations?

Do you have any mobility issues/ support requirements? ______

______

______

______

Please list any allergies, food intolerances or specific dietary needs we should be aware of when catering.

______

______

______

______

AMOUNT OWING

Per person / No. of delegates / Delegate category
$150 / $ / Conference 1.5 day pass: Current Members
$175 / $ / Conference 1.5 day pass: New & Renewing Members
$100 / $ / Conference Saturday-only pass: Current Members
$125 / $ / Conference Saturday-only pass: New & Renewing Members
TOTAL $

TAMS Members receive regular updates via the TAMS website, discounts for future events (2016 conference etc), quarterly TAMS E-Newsletter, member of online and face-to-face support groups and more. Please select your membership category or categories.

PAYMENT

☐Cheque or Money Order made out to “The Australasian Mastocytosis Society” attached to form

Post this to: PO Box 865

Port Macquarie NSW 2444

 / EFT (Electronic Funds Transfer)
Account Name: The Australasian Mastocytosis Society
BSB: 802 214
Account #: 132471

AGREEMENTS – In submitting this form, I agree:

☐ Not wear perfume or aftershave to the conference or related events

☐ If I cancel my attendance a 10% fee will be retained to cover administration costs

NOTE:When completing this form, simply insert the required information into the spaces provided, then save it to your own computer documents file. This form can then simply be attached to an email and sent directly to the committee at

Should you have any further questions, or specific requests for assistance in caring for children during the conference weekend, please also email the TAMS committee directly. Once we have a clearer idea of the needs for child care, the necessary arrangements and associated charges can be determined.

Please continue to complete the additional registration information pages below. This additional information will assist TAMS with future planning.

Thank you. We look forward to seeing you in Sydney.

The TAMS Committee

The Australasian Mastocytosis Society (INC9896639)

PO Box 865, Port Macquarie NSW 2444 | T. +61 2 6583 5080 |

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