Improving Healthcare International Convention 16

Improving Healthcare International Convention
16-18 November 2015
Pullman Albert Park, Melbourne
Register online at www.ihic.improve.org.au or return this completed form with payment to:
IHIC 2015 Meeting Managers
GPO Box 128
SYDNEY NSW 2001
AUSTRALIA
Please complete one form for each registrant. All fees are quoted in Australian Dollars (AUD) and are inclusive of
GST.
A. DELEGATE CONTACT INFORMATION (please use block letters)
TITLE (please circle)
Dr Miss Mr Mrs Ms A/Prof Prof
GIVEN NAME
SURNAME
ORGANISATION
POSITION
POSTAL ADDRESS
CITY/SUBURB
COUNTRY
TELEPHONE
MOBILE PHONE
FAX
EMAIL
STATE
POSTCODE
PREFERRED NAME ON NAME
BADGE
RACGP MEMBERSHIP NUMBER
(By providing your RACGP number the
Improvement Foundation can apply for CPD
points on your behalf)
REGISTRATION PROMO CODE
(if applicable)
www.ihic.improve.org.au
Improvement Foundation: 1800 771 522
B. REGISTRATION FEES
Category
2 Day Registration Fee
Endorsement Registration Fee
(if applicable)
Early Bird registration
before 11 September
2015
□ $1,100.00
Standard Registration
after 11 September
2015
□ $1,300.00
□ $880.00
□ $1040.00
B. Sub Total Registration Fee: A$
C. MASTERCLASSES
Masterclasses
Date
Time (from – to)
16 November 2015
13:30 – 17:00
□ $250
16 November 2015
13:30 – 17:00
□ $250
16 November 2015
13:30 – 17:00
□ $250
Support for Leaders of LargeScale Change
Mr Paul Plsek
Fee A$
Utilising Research to
Improve Patient Care
Dr John Ovretveit
Essentials of Optimising
Systems for High Value
Performance
Dr Marjorie Godfrey and Dr
Julie Johnson
C. Sub-Total Pre Conference Workshops: A$
D. SOCIAL PROGRAM
The Welcome Reception is included in your Delegate Registration Fee. If you require
additional tickets please indicate this below:
Event
Welcome Reception
Cost per ticket
$65.00
Number of tickets required
Total Cost
The Gala Dinner is not included in the Delegate Registration Fee. If you would like to
purchase tickets please indicate this below:
Event
Gala Dinner
Cost per ticket
$130.00
Number of tickets required
Total Cost
E. Sub-Total Additional Social Tickets: A$
www.ihic.improve.org.au
Improvement Foundation: 1800 771 522
E. PHN Session (for PHN Staff only)
The Improvement Foundation will be hosting a free session for PHN staff on Monday 16 November from 10.00am1.00pm. Please indicate if you will be attending:
Yes |
No
F. ACCOMMODATION
□ I do not require the Meeting Managers to book accommodation for me. I have made my own
arrangements.
□
Yes, I do require the Meeting managers to book accommodation on my behalf at the following. (A minimum one
night’s deposit must be paid at time of booking.)
Hotel
Pullman
Melbourne
Albert Park
Hotel
Mercure
Melbourne
Albert Park
Seasons
Heritage
Melbourne
Room Type
Room only rate per
room per night
Classic Room
Single
□ $215.00
Room and
Breakfast rate
per room per
night
N/A
Classic Room
Double
□ $215.00
N/A
Classic Twin
Room
□ $215.00
N/A
Mercure
Superior Room
Single
□ $155.00
N/A
Mercure
Superior Room
Double
□ $155.00
N/A
Mercure
Premium Room
Twin
□ $175.00
N/A
One Bedroom
Apartment
□ $135.00
SGL Rate:
Number of
Nights
Deposit
□ $160.00
DBL/TWN Rate:
□ $185.00
One Bedroom
Apartment with
Balcony
□ $155.00
SGL Rate:
□ $180.00
DBL/TWN Rate:
□ $205.00
Two Bedroom
Apartment
□ $225.00
SGL Rate: N/A
DBL/TWN Rate:
□ $275.00
www.ihic.improve.org.au
Improvement Foundation: 1800 771 522
Important - Please complete this section if you are booking accommodation through the Meeting Managers
Arrival/Check in Date:
Estimated Time of Arrival:
Departure/Check out Date:
Estimated Time of Departure:
I wish to guarantee early check in by pre-booking and paying for the previous night on: /
_
/
Please be advised that accommodation venues require all names of those staying on the premises for workplace, health
and safety purposes.
I will be sharing this room with
Special Requirements e.g. smoking/ non smoking room (subject to availability)
D. Sub-Total Accommodation: A$
NOTE: LATE ARRIVALS / NON ARRIVALS
Please indicate when you register, or notify the Convention Managers in writing, if you will arrive at your hotel after 18:00
hours. Failure to do so may result in your room being treated as a no-show and being released.
www.ihic.improve.org.au
Improvement Foundation: 1800 771 522
G. SPECIAL DIETARY REQUIREMENTS
Please specify any special dietary requirements. Every attempt will be made to meet
your requirements; however this may not be possible in every case.
□ Gluten Free
□ Lactose Intolerant
□ Allergy to Nuts
□ Halal
□ Vegan
□ Kosher
□ Allergy to Shellfish
□ Vegetarian
Other
G. MATERIAL DISTRIBUTION
□ YES – I consent to receiving information from Arinex Pty Limited or other Organisations on related
products or services from time to time.
□ NO – I do not consent
H. DELEGATE LIST
□
YES – please include my details as given in this form (and any subsequent amendment) in the
Delegate List produced for the Meeting which will be supplied to organising bodies, sponsors,
exhibitors and all delegates attending the Meeting.
□ NO - please do not include my details in the Delegate List.
www.ihic.improve.org.au
Improvement Foundation: 1800 771 522
I. DELEGATE PROFILE
1. Where did you hear about the Convention?

Advertisement

APCC update

E-mail

Facebook

IF eNews

IF website

Linkedin

qiCommunity Update

Twitter

Sponsor

Other (Please state
)
2. What sector or specialty group do you represent?

Aboriginal and Torres Strait Islander Sector

Allied Health Sector

Community Organisation

Consumer Group/Representative

Disability Sector

Education

Government

Health Specialist

Hospital

Not for Profit Organisation

Primary Care Heath Service

Technology

Other (Please specify):
www.ihic.improve.org.au
Improvement Foundation: 1800 771 522
J. PAYMENT AND CONDITIONS
Section B
Section C
Registration Fee
Pre Conference Workshops
$
$
Section D
Accommodation
Section E
Social Program
TOTAL FEE PAYABLE AND ENCLOSED
$
$
NOTE: Registrations will not be processed or confirmed until payment in full is received.
By completing this form you accept all terms and conditions as outlined on the
Convention website.
Please select your preferred payment option below:
□
Cheque: please find enclosed cheque/money order payable to Arinex Pty Limited for IHIC Convention 2015
□
Credit Card: please charge the total amount above to the following credit card
Mastercard
Visa
Diners Club
AMEX
Please note all transactions by credit card will appear on your statement as payment to: Conference by
Arinex Pty Limited.
Credit card number
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/ /
Validation Code:
Expiry Date:
/
Name on card:
Billing Address:
Signature:
Date:
/
/
NOTE:
1. Your registration will not be processed or confirmed if payment is not forwarded with this form.
2. Confirmation of your registration will be sent to you within 10 working days from receipt of your registration
form.
3. Earlybird registrations rates – form must be mailed by 11 September 2015.
For further registration terms and conditions please visit www.ihic.improve.org.au
www.ihic.improve.org.au
Improvement Foundation: 1800 771 522