Registration

Required fields are marked with an '*'. Payment is accepted via Visa or Mastercard ONLY.

Section A — Delegate's Details (One form per person)

Name (as will appear on your badge; please AVOID block capitals)

Title *

Specify if other *

First Name *

Surname *

Address

Line 1 *

Line 2

Line 3

City *

Postcode

State

Country *

Specify if other *

Institution

Hospital / Organisation *

Speciality / Profession *

Contact Details

Please enter phone numbers using international format, eg +64 9 123 4567

Telephone *

Mobile Phone

Email address *

Re-enter your email address *

Your tax invoice and receipt will be emailed to this address as a pdf document.

Special Requirements, if any

Diet

Regular

Vegetarian

Gluten free

Other, eg dietary, mobility

Section B — You and Your Privacy

The Privacy Act 1993 provides that, before your name and address details can be published in the list of delegates for distribution to other conference participants, you must give your consent. If this box is NOT ticked it is assumed that you agree to have your details published in the list and that we may contact you in the future regarding further meetings.

If you DO NOT wish your details to be included in the list of ACS delegates, or to be contacted about other meetings, please tick here

Section C — Conference Registration Fee

New Zealand Anaesthetic Registrars' Day

Held on Friday, 16 March 2012, this is open to all ANZCA Trainees, free of charge.

If you are an ANZCA Trainee and wish to attend the 2012 Registrars' Day, please tick here

Auckland City Symposium

To be eligible for early bird registration, registration must be completed on or before Friday, 17 February 2012.

Registration includes entry to the ACS conference, lunch, morning and afternoon tea, and the cocktail hour on Saturday, 17 March 2012. All fees include New Zealand Goods and Services Tax (15%). Please select the appropriate registration type –

Early bird

Standard

Consultant / Fellow

NZ$ 550.00

NZ$ 595.00

Registrar

NZ$ 295.00

NZ$ 350.00

Technician / Nurse / Allied Health

NZ$ 295.00

NZ$ 350.00

Not attending ACS

NZ$ 0.00

Section D — Cancellation Policy

Cancellations to the Auckland City Symposium prior to or on Friday, 17 February 2012 will attract a processing fee of NZ$ 30.00. After this date the cancellation fee will be 50% of the total registration cost. Failure to attend the conference will incur a penalty equal to 100% of the total registration cost.

To confirm you have read and accept these conditions, please tick here

ACS

Auckland City Symposium

An update on airway technology and management techniques