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Class of 1964

Class of 1964 Reunion: 28-30 November 2014

REGISTRATION FORM

Please complete this form and return it with your payment, by not later than 17 OCTOBER 2014 and return to:

Joan Tuff, Alumni & Bequest Officer, UCT Faculty of Health Sciences, Anzio Road, Observatory, 7925.

Telephone: +27 (0)21406 6686, or fax: +27 (0)21650 5010, email:

Your details

Name:

Address:

Email Telephone/mobile number:

Your payment South African Rands please

Tick your preferred payment method

1.  cheque (payable to “UCT”)

2.  direct (EFT) deposits

Bank: Standard Bank of South Africa, Rondebosch

Account name: UCT Sundries Account

Branch Code: 025009

Account Number: 071503 854

Type of Account: Current

Reference: 1964surname120098 eg 1964adams120098

3.  internet banking Same as direct deposits

Swift code SBZAZAJJ (foreign payments) – please include bank charges with your payment

For payment methods 2 or 3, forward a copy of your deposit slip by fax or email to Joan Tuff

Fax +27 (0) 650 5010 or +27 (0)86612 6390 Email:


4.  credit card

Authority for payment by CREDIT CARD to the University of Cape Town

Please debit my  American Express  MasterCard  Visa  Other:

Amount:

Card number

Last three digits on back of card:

Expiry date:

Today’s date:

Signature: …………………………………….

Fri, 28 Nov / 11h45 / Registration and Lunch, Mac Club, Medical School
13h15 / Tour of Medical School
15h00 / Tour of the Heart of Cape Town Museum, Groote Schuur Hospital
18h00 / Cocktail party – Institute of Infectious Disease & Molecular Medicine (IDM) building, Medical School Dress: Smart casual
Sat, 29 Nov / 8h30-12h30 / Academic Meeting – Wolfson Pavilion Lecture Theatre, IDM Building
12h45 / Lunch – foyer, IDM Building
Afternoon / At leisure
18h30 for 19h00 / Class photograph followed by Gala Dinner – Smuts Hall dining room
Dress: Black Tie/Dark Suit or long evening dress
Sun, 30 Nov / 09h00 / Mountain walk led by Fay Thornley
12h00 / Lunch – Rhodes Memorial Tea Room

Costs

Date / Event / Cost / Number attending / Total
Fri, 28 Nov / Registration (obligatory; per class member only) / R700.00 per classmate / R700.00
Lunch – Mac Club
Cash bar available / R120.00 per person
Heart of Cape Town Museum, Groote Schuur Hospital: Adults / R50.00 per person
Cocktail Party - Foyer, IDM Building / R140.00 per person
Sat, 29 Nov / Academic meeting – Wolfson Pavilion, IDM Building / No charge
Light Lunch – Foyer, IDM Building / R120.00 per person
Gala Dinner – Smuts Hall dining hall / R320.00 per person
Sun, 30 Nov / Lunch – Rhodes Memorial Tea Room / Own account (indicate number attending)

TOTAL PACKAGE (per class member): R1450.00

+ Spouse / Partner R 570.00 = R2200.00

Please note: In the event of a cancellation, a cancellation fee will be levied. Refunds may only be accommodated if confirmations for expenses such as catering, printing, photography, etc have not yet been made. Your understanding would be greatly appreciated.

Name tags

Classmate Partner

Name and Surname Name and Surname

Dietary preferences/allergies:

Walking disabilities:

Mountain Walk: Would you like to Fay Thornley on a mountain walk?

Yes No If yes, number attending

The following class members have agreed to speak:

Roger Melvill / The Brain at Altitude
Warwick Morris / Craniofacial Surgery
Paul Wilson / Chinese Export Porcelain: It's the Story that Matters
Judith Landau / The ARISE Model: A Multigenerational Approach for Enhancing Family & Community Connectedness, Prevention, Healing, And Engagement When Confronted With The Long-term Consequences Of Trauma
Dennis Huddleston / Rapid Recovery Knee Replacement Surgery
Chris Molteno / Neural Correlates of Prenatal Alcohol Exposure
Ruth Wannenburg / … of Aloes, Sangomas, Secrets and Things

Names of classmates who have indicated that they would like to attend thus far:

Ivan Berkowitz, Ed Coetzee, John Colley, Jim Crosier, Herschel Flax, Philip Garratt, Annette Goosen, Dennis Huddleston, Dawood Khan, Martin Kift, Horst Kirsten, Johan Koeslag, Judith Landau, Peter Levin, Mike Mair, Roger Melvill, Milton Meyers, Wilfred Millin, Chris Molteno, Warwick Morris, Barry Munnik, Dennis North Coombes, Ian Osborn, Jonathan Peter, Gerald Riemer, Jonathan Scher, Alan Scher, Lewis Sparks, Fay Thornley (Linder), Peter Turner, Jan van den Ende, Glenifer van Hoogstraten, Gerda Veldman, David Walker, Ruth Wannenberg, Susan Wells, Dudley Werner, David Wheatley, Paul Wilson, Lionel Wolff.

Booklet forms received thus far - DEADLINE 17 OCTOBER (questionnaire on page 4)

Ivan Berkowitz, Roy Cooke, Jim Crosier, Paul Du Plessis, Herschel Flax, Philip Garratt, Dennis Huddleston, Martin Kift, Johan Koeslag, Judith Landau, Peter Levin, Mike Mair, Roger Melvill, Wilfred Millin, Chris Molteno, Warwick Morris, Barry Munnik, Ian Osborn, Jonathan Peter, Gerald Riemer, Jonathan Scher, Lewis Sparks, Fay Thornley (Linder), Peter Turner, Jan van den Ende, Gerda Veldman, David Walker, Ruth Wannenburg, Dudley Werner, Paul Wilson, Lionel Wolff.

CLASS OF 1964

The Reunion Booklet – IF NOT ALREADY COMPLETED

Please complete this part whether you are attending the reunion or not.

Fill in the table below by TYPING in each answer. Be brief and include an ID size photograph as an attachment. Save the form as a word document, not a PDF, so that it can be copied and pasted into the booklet.

The completed form should be no longer than one page. Please note that you do not have to hit enter when filling in the form; the spacing will adjust automatically at the end of each line, therefore just click in each blank cell and type the individual answer. Please do not move or adjust the table or change the pre-set fonts.

Name
Home address
Code & country
Telephone (home)
Fax
Telephone (work)
Fax
Mobile
Email
Place of employment (if now retired, state last position held)
Field of Practice
Actual Job Description
Degrees (post grad)
What have you been doing since you graduated?
Tell us about your wife/partner, children and grandchildren
Hobbies, interests and sports
Achievements/Awards
Life’s memorable moments

Would you have any objection to this information being published in a UCT publication? YES NO

(we will not divulge your contact details)