Health Reform: Breaking the Stalemate
Patient-Centred Health Care Network

Strategy Workshop

August 10 2005

Registration and Payment Form 

           Please provide the following contact information

Name
Title
Organisation
Work Phone
Fax
Email
 Address
Address 
City
State
Postcode
Country

           Please describe your current role in the health system and your interests

TYPE OF REGISTRATION 

Fee

Unfunded Consumer $11
Community Organisation, Consumer Group, Self-Help Group $99
Self-Employed Practitioner   $176
Service Provider /Insurer /Consultant /Academic $264
Government /Policy Maker $330

Please indicate Type of Registration

         

I will send my cheque/money order to   Social Enterprise Partnerships,
2 Elm St, North Melbourne 3051

I understand that a tax invoice/receipt will be forwarded to me on receipt of payment. (If you require an invoice prior to making a payment, please indicate.)


         

BACK TO PATIENT-CENTRED HEALTH CARE NETWORK

          PRIVACY STATEMENT:  Registration details will be held in the strictest confidence and
          will not be passed onto a third party.

          CANCELLATIONS:  Cancellations must be notified in writing by 1 August 2005.

          Social Enterprise Partnerships Ltd
          ABN 47108742098
          2 Elm Street
          North Melbourne
          Phone (03) 9326 4481
          Fax (03) 9326 8030