Australian Rare Lung Disease Short Course 2017 Registration Form

Transcription

1 Australian Rare Lung Disease Short Course 2017 Registration Form Invitation to attend Lung Foundation Australia and the Thoracic Society of Australia and New Zealand (TSANZ) are pleased to invite you to attend the 3rd Biennial Australian Rare Lung Disease Short Course (ARLDSC) The ARLDSC returns to the beautiful city of Sydney in August 2017 and is expected to be even larger than previous events. The program includes a new scientific program with exciting and current sessions, including: IPF Abstract Oral Session PH Interesting Cases / Rare Lung Disease IPF Update What s Hot? Due to its multidisciplinary and interactive nature, the ARLDSC welcomes all: Physicians; Surgeons; Clinical scientists; Researchers; Nurses; and Pathologists REGISTRATIONS WILL BE ACCEPTED ON A FIRST COME, FIRST SERVED BASIS, PER REGISTRATION CATEGORY. REGISTRATION OPENS ON 20 th February We look forward to seeing returning delegates and some new faces at this year s ARLDSC. Yours sincerely, Jane Kerr General Manager Thoracic Cancer and Rare Lung Disease

2 Acknowledgement must go to the following people for their involvement in developing the conference program. Local Organising Committee Nicole Goh (Chair Rare Lung Disease National Advisory Committee) Tamera Corte Ian Glaspole Hubertus Jersmann Ian Glaspole Susanne Webster Lung Foundation Australia Heather Allan, CEO Jane Kerr, Program Director Amelia Parsons, Event Assistant Keynote speakers International Associate Professor David Lederer Columbia University Medical Centre. Australian Local speakers include key opinion leaders in rare lung diseases (details will be included in the program to come). Key Dates Abstract submissions open 12th December 2016 Registrations open 20th February 2017 Abstract submissions close 21st April 2017 Notification of accepted abstracts 5 th June 2017 Early bird registrations close 10 th July Conference commences 18 th 19 th August 2017 Scientific Program The program will be available online at the Lung Foundation Australia website:

3 Social program Friday 18 th August 2017 Cocktail Reception: Parkroyal Darling Harbour Abode Restaurant (after the final session on Friday 18 th August). Take this opportunity to relax with a drink and socialise with colleagues. Drinks and canapes will be served in the exhibition area and poster prizes will also be announced at this event. Cost: Additional adult tickets: Included in registration cost $A60 per person Cancellation policy The conference reserves the right to cancel or vary optional activities if minimum numbers are not reached. Regrettably, optional social function and additional ticket cancellations cannot be refunded if participation is cancelled less than 72 hours prior to the event. Disclaimer Lung Foundation Australia and their agents act only as organisers of these activities and do not accept responsibility for any act or omission on the part of the service providers. No liability is accepted for any inaccuracy, misdescription, delay, damage, death or personal injury. For your information Dress Smart casual attire is appropriate for short course sessions and the cocktail reception. Conference secretariat Lung Foundation Australia PO Box 1949 (Level 2/11 Finchley Street) Milton Qld 4064 Australia T: F: E: ameliap@lungfoundation.com.au W: Accommodation venues Reasonable accommodation rates have been offered by the Parkroyal Darling Harbour for those wanting to stay onsite. To arrange your stay during the Australian Rare Lung Disease Short Course 2017 contact Parkroyal Darling Harbour Reservations on: (02)

4 Registration information All fees are quoted in Australian dollars (AUD) and are inclusive of GST. Registration fees LFA Member Early Bird registration $400 Standard registration $500 Onsite / late registration $550 Nurse / P/T Student / Non-Medical Early bird registration $250 Standard registration $300 Onsite / late registration $400 Non-LFA member Early bird registration $480 Standard registration $580 Onsite / late registration $360 One day registrations Early registration $250 Regular registration $300 Exhibitor only registration $85 Cocktail reception (delegate) $60 Additional cocktail reception tickets $80 * Please note conference numbers are strictly limited. Registrations will be granted on a first come first serve basis. Late/on-site registration refers to those delegates who register on or after 7 th August 2017 or (pending availability) that pay to register upon arrival at the conference. Late/on-site registrations will incur an extra $50 AUD fee on top of the standard registration fee. Conference satchels and their contents cannot be guaranteed for late/on-site registrants. Registration cancellation policy Registration cancellations will not be accepted unless made in writing. Cancellations made before 18 th July will be refunded less $A100 to cover administration costs. No registration refunds will be made after this date. As an alternative to cancellation, your registration may be transferred to another person on or before 7 th August without incurring any cost penalty. Registration transfers made after 7 th August will incur an $A22 processing fee. The conference secretariat must be advised in writing of any alterations or transfers. Payment All prices are in Australian dollars and include GST. Cheques or drafts must be in Australian currency, drawn on an Australian bank and free of all charges. Payment by credit card is also acceptable. Faxed registration forms are acceptable only if payment is by credit card. Payment must accompany your registration form. Conference registration cannot be confirmed until payment is received. Payment must be received by the due date to receive the discount, otherwise the next level of payment will be charged. Also, please note accommodation cannot be booked until a deposit of at least one night s tariff or credit card details are received by the secretariat.

5 Privacy statement Your name, organisation and country/state of origin may be published on the delegate list which is provided to delegates at the event Should you not wish your details to be used for these purposes please indicate this on the registration form. If you have any questions regarding the details provided on the delegate list please contact the event assistant Communication By providing your address and contact details, you agree to receive s and other communications in relation to this event. You may opt out at any time by contacting the event assistant Website Visit the Lung Foundation Australia website for further details and information:

6 Registration form Part One Personal Details Title: First Name: Surname: Organisation: Position: Postal address: Telephone (work): Telephone (mobile): Fax: Special Requirements: Please note any specific dietary, wheelchair access or other requirements Please indicate your professional group Physician Scientist/Researcher Pathologist General Practitioner Student Trainee Other: Accompanying person: Title: First Name: Surname: Privacy I do not wish for my personal details (name, organisation, State, ) to be included in the Delegate List to be distributed to delegates, sponsors and exhibitors at the Rare Lung Disease Short Course. Part Two Registration Type Early (before 10 th July 2017) Standard Full Registration (LFA member $400 $500 Full Registration Non-LFA member $450 $580 Full Registration $250 $300 Student/Scientist/Trainee/Speaker/Nurse 1 day Registration $250 $300 Part 3 Social program and extras Event Attending Y/N - Number of guests Friday 18 th August 2017 Cocktail Reception Yes No No charge for delegates Friday 18 th August 2017 Additional Guest/s for cocktail reception No. of guests x $60 $60 per person Cost Subtotal Part 4 Total Payment Due Registration Fees (Part Two) Social Program and extras (Part 3) TOTAL DUE

7 Part 5 Payment Options Option A - I enclose a cheque or bank draft drawn on an Australian bank (in Australian dollars) made payable to Lung Foundation Australia. Option B - I would like to send payment by electronic funds transfer. Bank details are below: Account Holder Name: Lung Foundation Australia Financial Institution: Westpac Banking Corporation BSB: Account Number: Name of your bank:_ Date of transfer: Amount transferred: Please include delegate s name and/ or invoice number on the transfer details and fax remittance advice to the Secretariat. Acknowledgement cannot be sent unless these details are provided. Option C Please charge my credit card Visa Mastercard AMEX Credit card number: Cardholder s name Signature: Home address: Date: Expiry date: FORWARD THIS REGISTRATION FORM WITH PAYMENT TO: ARLDSC 2017 Secretariat, c/- Lung Foundation Australia, PO Box 1949, Milton, Qld 4064 Australia Phone: Fax: ameliap@lungfoundation.com If you are not from Australia and are paying by credit card, please authorise your bank to allow a charge from Australia. Please be aware that payment by AMEX card will incur a 2% service fee. We suggest you make a copy of this form for your own records. If payment has to be processed through a large organisation and may be delayed, please forward a separate copy of the registration form to the Secretariat. However, registrations will only be acknowledged once payment has been received.