AMPS PROJECT-AUSTRALIA

ABN 50 327 934 894

Monday 3rd September to Friday 88th September 2017

Holmesglen Conference Centre

Warrigal Road

CHADSTONE

AMPS Registration Form

Course fees include:

¨  five days of AMPS training

¨  the AMPS manual, provided to course participants

¨  personalised AMPS computer scoring program, provided to trained raters at the end of course

¨  Morning & Afternoon tea supplied each day.

Follow-up testing of 10 people to achieve reliability as an AMPS rafter is expected.

Name:
Contact Address Home:
Contact Address WorkPlace:
Phone (wk): / Fax (wk):
Phone (hm): / Occupational Therapy member no:
Email address:
Professional Qualifications (if OT student, specify course enrolled in):
Practice Area(s):

I enclose the following payment for AMPS Course Fees:

Occupational Therapy Australia member / $1,800.00 / [ ]
Qualified OT non- member / $2,200.00 / [ ]
Occupational Therapy Australia student member / $1,300.00 / [ ]
OT student non-member / $1,500.00 / [ ]

PAYMENT DETAILS

I WISH TO PAY BY

CREDIT CARD PURCHASE DETAILS

Credit card type: r VISA r Bankcard r Mastercard
Card number:
Expiry Date: ____ / ____ CVV Code : ______
Signature______
Name appearing on credit card:______
Total amount due: ______

OR

PLEASE INVOICE MY EMPLOYER

Organisation: ______

Attention : ______

Address: ______

Cancellations & Refunds

AMPS Project Australia reserves the right to cancel or postpone any event. If this occurs, registration fees paid will be refunded in full, but AMPS Project bears no responsibility for any other costs incurred (such as flights, accommodation, travel expenses or loss of income).

Should you be unable to attend an event for which you have registered and paid, a substitute delegate is welcome to attend in your place provided you notify us in advance of the event date. If the substitute attendee is not a member, the non-member fee will apply and extra payment will be due and payable before the event date.

If you cancel your registration for an event (and no substitute delegate is arranged), a refund (equivalent to 90% of the registration fee paid) will be given provided a written cancellation is received by us prior to the closing date. Cancellation after the closing date will be ineligible for a refund.

Send this completed REGISTRATION FORM and PAYMENT to:

Occupational Therapy Australia

Attn: Cheryl Bermingham

6/340 Gore Street

Fitzroy Vic 306

Email :

“AMPS Project Australiais committed to supporting the National Privacy Principles. We will only collect and store information about you that is necessary. The information you provide may be used to offer, provide and improve our services to you. We will not otherwise, without your consent, use or disclose the information you provide for any other purposes unless it would reasonably be expected that such a purpose is related to the offer, provision and improvement ofAMPS Project Australia services and benefits to you or where such purpose is permitted or required by law.

Are prepared to have your name and address made available toAMPS Project Australia for undertaking research?

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