Alzheimers.org.za



Registration Form

ONE-DAY SEMINAR

‘Every 3 Seconds’

Date: Wednesday 12th September 2018

Venue: Rosebank Union Church, Corner William Nicol &

St Andrews Roads, Hurlingham, Sandton

Please note: A separate registration form must be completed for each attendee

Costs include VAT: R500

Students: R300

Individuals: R500 Paid up individual Associates of Alzheimer’s South Africa: R450

Paid up Affiliate Organizations of Alzheimer’s South Africa: R450 per person for 1st 2 attendees, thereafter R500 pp.

People with dementia: Free

Early Bird Special: R400 per person to 3rd July.

CPD points: HPCSA: Ethics: Application in progress SACSSP: Application in progress

SAPC and SANC: a certificate of attendance will be issued

|Surname |First Name |

|Place of work | |

|Health profession | |

|Student (Please provide student number) | |

|Member of Alzheimer’s Association? |YES NO |

|Person with Dementia? |YES NO |

|Day contact telephone number | |

|Email address | |

|Fax number | |

|Registration fee paid (amount) | |

Provision will be made for vegetarian lunches.

Registration for CPD points if applicable:

|Name and Surname |Professional Council |Registration number |

| | | |

Gautrain (strongly recommended): take train to Sandton station, catch the Randburg bus route to corner of Sandton Drive and William Nicol Drive. Cross William Nicol Drive to the church on corner. Walking distance from Gautrain station is 2,8 km (approx. 33min walk)

Payment details:

Account holder: Alzheimer’s South Africa (SA)

Bank: First National Bank

Branch: Northcliff Square

Branch code: 253705

Account no: 62004774106

Reference for bank deposits: SEM and your surname

Please register before 6th September 2017.

Please send this completed form, with your proof of payment to: Email: admingp@.za Fax: 086 634 2620/3

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