Implementing and Embedding Evidence
Based Practice Institute Registration Form
Date:
9 - 11 March 2016
Time:
8.30am (for a 9.00am start) until 5.00pm
Venue:
ANMF Education Centre, 191 Torrens Road, Ridleyton
REGISTRATION FORM
Name:
Organisation:
Address:
Postcode:
Email:
Mobile:
Work phone:
Dietary requirements:
COST
Members
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$350.00
Non Members
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$450.00
METHOD OF PAYMENT (Complete form for each employee)
Invoice for Organisation:
For attention of: .........................................................................................................
Organisation:...............................................................................................................
Phone Number: Email address:...................................................................................
Credit Card details:
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Visa
MasterCard
Cheque payable to:
ANMF (SA Branch)
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Expiry date
• Payment must accompany the registration form in order to be processed.
• On-site registration will not be accepted.
• Confirmation of registration will be emailed upon receipt of registration form and payment.
CANCELLATION / REFUND POLICY
ANMF (SA Branch) reserves the right to cancel or reschedule this event and you will be notified of refund options should this occur.
Alternatively, a full refund will be provided where a participant gives more than ten (10) working days’ notice.
INSTITUTE LEARNING MATERIALS
Institute materials are considerable in volume when printed in their entirety. Printed copies of each PowerPoint will not be provided. However, a
workbook outlining learning outcomes for each session; application exercises; references/resources for additional learning will be provided.
Photos will be taken during the event for future promotional uses. Does ANMF (SA Branch) have your permission to use any photos you may be
in?
 Yes
 No
During each Institute a Networking Contact List is created for each participant to take home and use for future communication with other
participants. Would you like to be included in the Networking Contact list for this event?
 Yes  No
Completed registration form can be sent to:
Email: [email protected] - Fax: (08) 8334 1901 (attention: Jenny Pavlakos) OR
Mail: PO Box 861, Regency Park SA 5942 (attention: Jenny Pavlakos)
SUBMIT
Authorised by Adj Assoc Professor Elizabeth Dabars AM, CEO/Secretary,
ANMF (SA Branch) ABN 95 969 485 175, 191 Torrens Road, Ridleyton, SA 5008