All Registrations, Including Payment Must Be Received by 30 August 2017

All registrations, including payment must be received by 30 August 2017

Name: / Surname:
Organisation: / Industry:
Student: / Yes No / Course:
Address:
State: / Postcode:
Phone: / Mobile:
Email:
Facebook:
Twitter:
LinkedIn:
DIETARY REQUIREMENTS:
Do you have any specific dietary requirements?Please specify:
MEDICAL CONDITIONS:
Do you have any allergies or medical conditions you would like us to know about in case of emergency? Is so please provide details below:
EMERGENCY CONTACT DETAILS:
Emergency Contact Name:
Relationship:
Emergency Contact Telephone Number:
INFORMATION SHARING:
Are you happy for your name, organisation, industry, state and email to be shared with other delegates? / YES NO
TALENT RELEASE AUTHORITY:
Do you understand that by completing the questions below, you are giving permission for AWiA Ltd to use your image and/or audio-visual recordings as specified in the questions below? / YES NO
Do you agree to appear in visual and or audio recordings made at the 2017 AWiA Conference which can be used in documents, advertisements and other promotional material published by Australian Women in Agriculture Ltd (AWiA)? / YES NO
Do you give permission for your name and any visual and/or audio recordings of you taken at the 2017 AWiA Conference to be used in advertisements, documents and other promotional materials including social media published by AWiA Ltd? / YES NO
Are you free to appear in the proposed advertisements, documents and other promotional materials including social media published by AWiA Ltd? / YES NO
In addition to the aforementioned materials, doyou agree for the use of your image and/or other audio-visual recordings of you being used in social media generated by AWiA Ltd? / YES NO
Where ever possible AWiA Ltd is understanding of cultural, family and personal sensitivities and will consider these in any uses of your image and/or audio-visual recordings of you.
Are you of Aboriginal or Torres Strait Islander descent? / YES NO
Isthere anything specific or special you would like AWiA to consider when using your image and/or your audio-visual recordings? / YES NO
If yes, please provide details:
CONFERENCE TICKETS / Cost / No. of Tickets / Total
AWiA Member *** Early Bird registration includes Friday Cocktail Event, Saturday, Saturday Gala Dinner & Sunday conference. / $390
Non Member *** Early Bird registration includes Friday Cocktail Event, Saturday, Saturday Gala Dinner & Sunday conference. / $490
AWiA Member *** Full registration includes Friday Cocktail Event, Saturday, Saturday Gala Dinner & Sunday conference. / $430
Non Member *** Full registration includes Friday Cocktail Event, Saturday, Saturday Gala Dinner & Sunday conference. / $500
Full Time Student Registration includes Friday Cocktail Event, Saturday, Saturday Gala Dinner & Sunday conference. / $390
Friday Tour to Food Connect Brisbane, Salisbury / $30
Sunday Tour to Pretty Produce, Lamb Island / $70
Sunday Tour to Sirromet Winery, Mt Cotton / $40
AWiA Member Friday Night Cocktail Function / $70
Non Member Friday Night Cocktail Function / $80
AWiA Member Saturday Night Gala Dinner Cruise: / $120
Non Member Saturday Night Gala Dinner Cruise: / $140
Saturday Day Conference Sessions / $220
Sunday Day Conference Sessions / $100
TOTAL CONFERNCE COSTS:
CHEQUE DETAILS:
Please address all cheques to Australian Women in Agriculture
AMOUNT:
DIRECT DEBIT DETAILS:
Please deposit funds, directly into the AWiA bank account, using the details below. Please use your name as the reference.
Account Name: / Australian Women in Agriculture
Bank: / Westpac
BSB: / 037 608
Account Number: / 524 119
Amount Paid:
Reference
CREDIT CARD DETAILS:
Type of Card: / VISA MASTERCARD (Please circle)
Name on Card:
Card Number:
Expiry Date:
CVV:
Signature:
Date:
NAME:
SIGNATURE:
DATE:
RETURN CONFERNCE REGISTRATIONS TO:
AWiA TREASURER / Maria Brown-Shepherd
Email: /
Post: / 86 McPhersons Road, Mundoona VIC 3635
Mobile: / 0407 269 692