FPQ MEDICAL AND HEALTH professional Course Registration Form

This form is designed to be completed, printed and posted/faxed with payment or contact FPQ on 07 3250 0240.
Post: Family Planning Queensland, PO Box 215, Fortitude Valley, Qld 4006 Fax: 07 3250 0294 - ABN 61 009 860 164.

I understand that by lodging this form I am agreeing to FPQ's Terms and Conditions on Course Registration and Code of Conduct.

Please note: All courses and workshops for 2012 may be subject to price change

Date:
Contact Name:	Title	Ms Mrs Mr Dr
organisation & address:
organisation & address:	postcode:
mailing Address:
mailing Address:	postcode:
Home Address:
Phone:	Mobile:
email:	fax:
medical/nursing registration no.	qa&cpd ref. no.
Do you work in: General practice setting Community health Indigenous health Hospital Specialist sexual & reproductive health service Other How did you hear about this course? FPQ will keep you updated about FPQ courses and news via email. Tick if you do not want this.

Cancellation Policy: Cancellation from course enrolment will incur the following fees: more than 28 days from course date -10% of course fee;14 to 28 days from course date - 25% of course fee; less than 14 days from course date - 50% of course fee. For cancellation or non attendance on day of course there will be no refund. Transfer to another course is available up to 14 days prior to course commencement with an administration fee of $50.00. Where the course is cancelled by FPQ the participant will be entitled to a full refund of fees paid. FPQ is not responsible for travel-related costs that may be incurred as a result of cancellations.

Health Professional courses:		Cost GST Incl.	Number Attending
	Introduction to Sexual and Reproductive Health Theory (self directed learning package)	$645
	Sexual and Reproductive Health Clinical Attachment Module - Dates individually negotiated	$605
	IMG GP Cervical Screening Update workshop - Friday 17 February 2012 - Brisbane	$100 (refunded on attendance at workshop)
	The Family Planning Australia Certificate in Sexual and Reproductive Health - Theoretical Component (for Medical Practitioners) ($1700 - full price; $1540 - early bird & GP Registrar; $1100 - theory only; $605 - clinical training only) 4 to 9 March 2012 - Brisbane	$1700 $1540 $1100 $605
	Connections workshop - Friday 20 April 2012	$330
	Contraception overview (suitable for GP's, DRANZCOG candidates and nurse practitioners) - Friday 27 April 2012 - Brisbane	$425
	Pap Smear Provider Module - 2, 3, 4 May 2012 - Brisbane	$1100
	The Family Planning Australia Certificate in Sexual and Reproductive Health - Theoretical Component (for Medical Practitioners) ($1700 - full price; $1540 - early bird & GP Registrar; $1100 - theory only; $605 - clinical training only) 27 May to 1 June 2012	$1700 $1540 $1100 $605
	IMG GP Cervical Screening Update workshop - Friday 15 June 2012 - Brisbane	$100 (refunded on attendance at workshop)
	Pap Smear Provider Module - 25, 26, 27 July 2012 - Brisbane	$1100
	Clinical Aspects of Sexual & Reproductive Health - 30 July to 1 August 2012 - Brisbane	$525 $425* *$100 discount if booked at same time as Pap Smear Provider Module
	IMG GP Cervical Screening Update workshop - Friday 3 August 2012 - Brisbane	$100 (refunded on attendance at workshop)
	Contraception overview (suitable for GP's, DRANZCOG candidates and nurse practitioners) - Friday 10 August 2012 - Brisbane	$425
	Connections workshop - Saturday 11 August 2012	$330
	The Family Planning Australia Certificate in Sexual and Reproductive Health - Theoretical Component (for Medical Practitioners) ($1700 - full price; $1540 - early bird & GP Registrar; $1100 - theory only; $605 - clinical training only) 26 to 31 August 2012 - Brisbane (subject to price change)	$1700 $1540 $1100 $605
	Pap Smear Provider Module - 10, 11, 12 October - Brisbane	$1100
	Cervical Screening Update workshop - Friday 23 November 2012 - Brisbane	$100 (refunded on attendance at workshop)
	Contraception overview (suitable for GP's, DRANZCOG candidates and nurse practitioners) - Friday 30 November 2012 - Brisbane	$425

OFFICE USE ONLY:
Date received:		participant notified of receipt:	Date:
copy to:	Training Programs Administration Officer: Purchasing & Stores/Debtors Officer:

paying by:
Cheque	For $ encl.
invoice	Please invoice (Company order form should accompany this form) Order Number:
Credit Card	Visa ............Mastercard .........
	Credit Card Number:	3 digit security no.
	Name on card:	Expiry date: ...
	Signature:______________________________	Please debit: $
Invoice/receipt will be issued for Tax purposes.

FPQ MEDICAL AND HEALTH professional Course Registration Form

Do you work in: General practice setting Community health Indigenous health Hospital Specialist sexual & reproductive health service Other How did you hear about this course? FPQ will keep you updated about FPQ courses and news via email. Tick if you do not want this.

Invoice/receipt will be issued for Tax purposes.

Do you work in:
General practice setting Community health Indigenous health Hospital
Specialist sexual & reproductive health service Other
How did you hear about this course?
FPQ will keep you updated about FPQ courses and news via email. Tick if you do not want this.