Way to Play Programme 2015
(One Day)
Registration Form
Location of Way to Play course:
PASG - 7 March
Personal Details
First Name:
Surname:
Organisation name: (if applicable)
Full address:
Phone: (inc area code)
Mobile Phone:
Email address:
Are you a: (please check a
box, and provide details)
Professional supporting a person on the
spectrum
(please specify i.e. Teacher)
Family member / person on the spectrum
(please specify i.e. Parent)
Ethnicity: (Collected for funding applications)
Payment Information – GST number 64-234-382
When completed this registration form is your tax invoice, please keep a copy for your records
Course Cost:
Parents/caregivers/whānau: There is no cost, due to generous funding from SKIP (Ministry of Social Development).
Professionals:
$80 per person
Amount Paid:
$
Cheque
Date Paid
Please make cheques payable to ‘Autism New Zealand’
Card Number:
Visa
/
Mastercard
Name on Card:
Expiry: i.e.00/00
Direct Banking
CCV Number:
3 digit on back of card
Account details: Autism New Zealand 03 0866 0356307 01
Direct banking reference: W2P, location, and participant’s name
Name, email address and physical address of person invoice should be sent to:
Invoice
When completed, please return to Autism New Zealand:
Postal: PO Box 6455 Marion Square, Wellington
Fax: 04 803 3502
Email: [email protected]
Note: The course runs from 9.30am – 3.30pm (Maximum number: 25 people, minimum number: 10 people)
Cancellation Policy: Cancellations must be sent in writing, (mailed or emailed), to Autism New Zealand. Cancellations received up to 30 days prior to the training
date receive a full refund, less a 10% handling fee. Cancellations received less than 30 days and up to seven days prior to the Training will receive a 50% refund. No
refunds will be given for cancellations received within seven days of the training; however a substitute delegate may be nominated.