The Royal Australian and New Zealand College of Psychiatrists

The Royal Australian and New Zealand College of Psychiatrists
2014 New Zealand Conference
Wednesday 15 – Friday 17 October 2014
Otago Museum, Dunedin, New Zealand
www.ranzcp2014.co.nz
DELEGATE REGISTRATION FORM
Prices Quoted are in NZD$ and are Inclusive of 15% GST
GST Registration Number: 93-388-283
(complete one form per delegate, and all sections)
REGISTRANT DETAILS:
Last Name:
……………………………………………………….. Title: ……………………………… First Name:
………………………………………………….……………..
(Prof, Dr, Mr, Mrs, other)
Name as you wish it to appear on your name badge: ………………………………………………………………………………………………………………………………………
Organisation | Company:
………………………………………………………………………………………………………………………………………………………………………..
Mailing Address:
……………………………………………………………………………………………………………………………………………………………………….
City|Town:
……………………………………………………………………………………………………………………………………………………………………….
State:
……………………………………………… Country: ……………………………………….. Post Code:…………………………………………..
Contact Telephone:
................................................................... Mobile:
………………………………………………………………………….
For emergency purposes, please give contact details: …………………………………………………………………………………………………………………………………...
Email Address:
…………………………………………………………………………………………………………………………………………….…………………………
Dietary Requirements (please  if appropriate):  Gluten Free
 Other (please state)
 Halal
 Kosher
 Lactose Free  Nut Free
 Vegetarian
 Vegan
………………………………………………………………………………………………………
New Zealand Privacy Act 1993: The Privacy Act 1993 provides that your name and contact details cannot be published in the list of conference
delegates for distribution to fellow delegates, exhibitors, or any other party without your consent. If you do not wish to be included in the delegate list
please tick 
 I require wheelchair access or special assistance. Please advise …………………………………………………………………………………………………………………………
CONFERENCE REGISTRATIONS:
Tick

Registration Category



Psychiatrist – Full Registration



Trainee/GP/Health Professional – Full Registration
Non-Psychiatrist - Full Registration
Psychiatrist – Day Registration
o Wednesday
o Thursday
Trainee/GP/Health Professional – Day Registration
o Wednesday
o Thursday
Non-Psychiatrist – Day Registration
o Wednesday
o Thursday
Before 7 September
From 8 September
$1,000.00
$1,100.00
$545.00
$600.00
$1300.00
$1300.00
$545.00
$545.00
$340.00
$340.00
$650.00
$650.00
Delegate Name _____________________________________________________________________________________________
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ACCOMMODATION
The Otago Museum is the conference venue and preferred accommodation rates are available at the following hotels. Prices are listed as
per room, per night and based on single, twin or double occupancy unless otherwise stated. Rooms will be held until 7 September 2014
when the block will be released and bookings will be subject to availability. Credit card details are required to secure your booking, but you
may still select to pay for your registration on invoice. Please check the conference website for cancellation policies, check-in and check-out
times. If you wish to change or cancel your accommodation please contact the conference manager [email protected] Please do not
contact the hotel directly.
Venue
Tick

Scenic Hotel Southern Cross
Room Type
Room Only
Per room per night

Run of House Single, Twin or Double
$201.25

Run of House Single, Twin or Double
$182.00

Run of House Single, Twin or Double
$145.00

Run of House Single, Twin or Double
$125.00
Cnr Princes and High Streets, Dunedin
(12 minutes’ walk from venue)
Park Regis Dunedin
310 Princess Street, Dunedin
(12 minutes’ walk from venue)
Kingsgate Hotel Dunedin
10 Smith Street, Dunedin
(10 minutes’ walk from venue)
Quality Hotel Cargills
678 George St, Dunedin
(5 minutes’ walk from venue)
Check-in Date:
........................................................
Check-out Date:
............................................................. Total Nights: ..............
Notes/Requirements: ..................................................................................................................................................
Please indicate room preferences here:
 Double/Single Occupancy
 Twin Occupancy sharing with ……………………………………………..
(one bed)
(two beds)
SOCIAL FUNCTIONS
Please ensure you indicate during registration whether you would like a ticket to the social functions. We are required to give final
numbers in advance and may not be able to accommodate your request for tickets if you register at the conference. Please check your
registration confirmation carefully.
Tick

Social Function

Welcome Reception –1 x ticket included in Full Registration
Wednesday at 5.30pm.
Welcome Reception - Additional Ticket
Wednesday at 5.30pm
Conference Dinner – Not included in Registration Fees
Thursday at 7pm
Conference Dinner – Additional Ticket
Thursday at 7pm



NZ$ GST
Inclusive
$0.00
$45.00
$135.00
$135.00
Additional Ticket Name: ………………………………………………………………… Special Dietary Requirements: …………….………………………………………..
Delegate Name _____________________________________________________________________________________________
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PAYMENT SUMMARY
Your payment must accompany the completed registration form and should be sent to the conference managers. Faxed registrations are
accepted only if payment is made by credit card. If you are submitting a copy of your registration form to your funding body for payment,
please fax through your completed registration form to +64 7 823 2316. An invoice will then be generated including payment instructions
which can then be sent to your accounts team for processing. Credit card statements will show debit as Outshine Ltd.
Registrations
$__________________
Social Functions
$__________________
Total NZ$ inclusive of 15% GST
$
PAYMENT METHOD DETAILS (PLEASE TICK YOUR CHOSEN METHOD)
Direct Credit / Electronic funds transfer (EFT) into the following bank account:
Bank: Kiwibank | Account Name: Outshine Limited – RANZCP NZ 2014| Account Number: 38 9004 0892895 09
Reference: Surname and Invoice Number
To assist in the allocation of your EFT payment, please fax or email remittance advice (which must include your name and organisation) to
+64 7 823 2316 or [email protected] immediately after payment.
Bank Cheque: In New Zealand Dollars and Payable to : Outshine Ltd – RANZCP and send to Outshine, PO Box 896, Cambridge 3450
 Credit card: All charges as per this form are to be debited to:
 MasterCard
Visa
 Credit card: Do not charge my credit card for registration, but secure my accommodation booking
Cardholder’s name:
Credit card number:
CDS/Security code:
Cardholder’s signature:
Expiry date:
CANCELLATION TERMS AND CONDITIONS
All cancellations must be made in writing to the conference manager [email protected] RANZCP will not refund registration fees for
st
cancellations made after 1 October 2014, unless there are exceptional circumstances. All applications will be considered on a case by case
basis. Refund of registration fees will incur an administrative fee of $50.00 including GST which will be deducted before registration fees
are refunded.
Please forward completed registration form with payment to the Conference Managers:
Outshine, PO Box 896, Cambridge 3450, New Zealand
Tel: +64 9 940 6676 | Fax: +64 7 823 2316
Website: www.ranzcp2014.co.nz | Email: [email protected]
Delegate Name _____________________________________________________________________________________________
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