Please complete one registration form per family

Please complete full details of medical practitioners, partners and children who wish participate in the conference activities.

Participant

Title
First Name
Surname
Organisation/Practice
Address
Telephone
E-mail

Partner

Title
First Name
Surname

Accompanying Children

Child's name	Age
Child's name	Age
Child's name	Age
Child's name	Age
Is child minding the required? Yes	No

Please complete all the following categories:
The registration desk for conference delegates will be open from 5.30p.m., alternatively you may wish to register from 8 a.m. on Saturday morning.

Friday 9th November

Welcome, 1st floor, Ballroom 3, Sebel Playford

Please indicate numbers attending (partner & children welcome)

Special requirements/dietary: Yes No

Please Specify:

Saturday 10th November
Please complete this section if you are a rural doctor and are attending the conference. Please tick one only

Morning & Afternoon (including lunch) Yes         No

Morning & Afternoon (lunch not included) Yes         No

Afternoon only (lunch not included) Yes         No

Special requirements/dietary: Yes         No

Please Specify:

RDASA AGM (approximate start time 3:30 p.m.)         Yes         No

Conference Dinner
Please complete this section for medical practitioners and partners attending the dinner

Pre dinner drinks 6:30 p.m. Self         Self & Spouse

Dinner 7 p.m. Self         Self & Spouse

Special requirements/dietary: Yes         No

Please Specify:

Sunday 11th November

Morning session (lunch not included) Yes         No

RMFN Networking Weekend

Please complete this section if you are a partner of a medical practitioner and are attending the conference.

Saturday 10th November

Afternoon tea	Yes No
Special requirements/dietary	Yes No

Please Specify:

Sunday 11th November (please tick one only)

Planning your financial future	Yes No
Bushwalking on Adelaide's doorstep	Yes No

Children's Activity Program

Please complete this section if your child(ren) wish to participate in this program. The Children’s Activity Program is for children aged 5 and over. Children aged up to 5 can also attend the program with a parent accompanying them. Lunch will be provided for the child, accompanying parents can purchase their lunch.

Saturday 10th November

Adelaide Zoo	Yes No
Number attending (including parents, if applicable)
Special requirements/dietary	Yes No

Please Specify:

Saturday Evening

6:00 to 12:00 Child care movies & meal

Yes No

Sunday 11th November

10 pin bowling	Yes No
Number attending (including parents, if applicable)

Accommodation Requirements

Accommodation costs for this conference are free to all rural doctors and their families. However your accommodation requirements need to be received by 19th October to enable us to make the necessary arrangements. Accommodation cannot be guaranteed for any requests received after this date.

Accommodation will be provided at a number of hotels and you will be advised upon registration.

I/We would like to stay (please complete all sections that apply)

Friday Night	Saturday Night
Number of Adults:
Children
Ages of Children

Special requirements, i.e. cot, wheelchair access, etc

I am aware that my children may be sleeping in the same room

By clicking on the "Submit" button below, your registration details will be submitted to the Rural Doctors Workforce Agency

Once registration details have been received a detailed confirmation of attendance will be sent out.

The Rural Doctors Workforce Agency is funded by the State Government Department of Health and the Australian Government Department of Health and Ageing