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2009 Inaugural Annual Medical Education Symposium registration form

Registration closes 6 March 2009

Title	(If other, please specify)

Last name	*

First name	*


Position


Department

Organisation	*

Address	*



Email address	*

Phone number	*

Special requirements
(e.g. vegetarian,
disabled access)

Preferred name
(for name tag)

If you would like to offer a short presentation?

If you would like to offer a short presentation please contact Robyn.Hill@med.monash.edu.au

Registration option

		Attending
		Yes	No
Registration option *	Friday 20 March, 2009 – 9.00 a.m. - 5.00 p.m.
	Saturday 21 March, 2009 – 9.00 a.m. - 3.00 p.m.
	Symposium Dinner Date: Friday 20 March, 2009 Time: 7.00 p.m. - 11.00 p.m. Venue: The Terrace Café, The Century Inn, Princes Highway, Traralgon Dress: Semi formal



Note: * indicates mandatory field. Please note, after submitting this form you will be prompted to answer a simple question as a security measure.

Accommodation

Accommodation for the nights of 19th, 20th and 21st March 2009 have been reserved at The Century Inn.
Please call +61 3 5173 9400,
fax +61 3 5176 1910
or email Function@centuryinn.com.au and quote Gippsland Medical School conference to book your accommodation.

Enquiries or further information

Contact: Susan Smith
Email: susan.smith@med.monash.edu.au
Telephone: +61 3 9902 6280
Facsimile: +61 3 9902 6841