REGISTRATION FORM

Please print and complete this form and return with your payment as soon as possible
(Registrations and/or payments received after Tuesday 20th January 2004 will attract the Late Fee.)

Personal Details (Please Print)

Dr/Mr/Mrs/Ms_____ First name:___________________ Surname:_____________________

Mailing address:_____________________________________________________________

_________________________________________________________________________

Phone:_______________ Fax:_____________________ Email:_______________________

Preferred name and institutional affiliation for name tag:

_________________________________________________________________________

I wish to attend ( please tick )Cost(GST incl.)
Population Screening (Feb 16-19)__ $ ____________
Two-day option (Feb 16-17) __ $ ____________
Signature________________________________________ Total $_____________
TOTAL AMOUNT ENCLOSED * (Cheque/Cash) $ _____________

Important notes:

  1. Include payment with enrolment to secure a place.
  2. Any payment made is fully refundable in the event that your chosen course is full.
  3. A limit to the number of participants applies to all courses on a first come first in basis.
  4. Cancellations will result in a refund less a $50 administration fee

* Please make cheques payable to 'The University of Otago' (GST receipts will only be issued on request) 

FOR STATISTICAL PURPOSES ONLY- required by Ministry of Education
Ethnic group	_____________
NZ or Australian citizen/permanent resident	Y/N
Date of birth	_____________
Male/Female

Please send registration to: 

Summer School Administrator, 
Department of Public Health, 
Wellington School of Medicine and Health Sciences, 
PO Box 7343,
Wellington South, NEW ZEALAND.