The Royal Children’s Hospital
ABN: 35 655 720 546
Allergy Education Day
Saturday 8th August 2015
REGISTRATION FORM /TAX INVOICE
This Registration Form becomes a Tax Invoice on receipt of Payment
One Registration Form per Participant
First Name:
Surname:
Primary Contact Address:
Hospital / Department:
Telephone (Work):
Fax (Work):
Email Address (Please print):
Dietary Requirements:
Registration Fee: $150.00 per participant (GST inclusive)
PAYMENT DETAILS: (Please tick)
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Cheque/Money Order made payable to “The Royal Children’s Hospital”
Credit Card (please complete details)
□ Visa □ MasterCard (Preferred)
Card Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Expiry Date: ______ / ______ Amount:____________________
Cardholder’s Name:
_________________________________
Signature:
_________________________________
Registration Deadline: Friday 31st July 2015 (for catering purposes)
Please complete the registration form, attach/insert payment details and send to: carol.whitehead@rch.org.au
Or to
Carol Whitehead – Department of Allergy & Immunology
Your question for the expert panel
The Royal Children’s Hospital
50 Flemington Road
Parkville VIC 3052
Tel: 9345 4235
or fax completed registration form to: 03 9345 4848