2019 CCSSA Refresher Course

Register

Kindly complete this form and submit it before 15 October 2019.

The Congress Organisers will issue an invoice upon receipt of your Registration Form. Banking details will be on the invoice. When effecting payment, please use your name and surname or account number (which appears on the invoice) as the reference.

Surname *

Initials *

Title *

Name * The name to be printed on your name tag e.g. Busi Seoka.

Email Address *

Cellphone Number *

Work Telephone Number *

Institution/Organisation *

City/Town *

Membership Number

HPCSA Number

To who should we make out the invoice? *

Myself

My institution

Address * Full address for invoice.

Postal Code *

Please select type of registration *

CCSSA Members/Non-members

Registrars, Nurses and Allied Health Workers

Are you a CCSSA member? *

Yes

Please send us a copy of your CCSSA membership card.

Which days will you attend? *

Full Attendance

Saturday, 23 November

Sunday, 24 November

Will you attend the Official Welcome function, Friday, 22 November? *

Yes

Will you attend the Informal Function, Saturday, 23 November? *

Yes

Do you have any special dietary requirements (e.g. Halaal, vegetarian, etc.)?

Due you require Kosher meals (surcharge of R100.00 per day) *

Did you book accommodation at one of the following hotels/guest houses? *

Protea Hotel Willow Lake
Aha Bloemfontein Hotel
Anta Boga Boutique Hotel
College Lodge
La Vie & Rose Lodge
Palm Lodge
City Lodge Hotel

Yes

Do you want to make use of the transport between one of the above-mentioned hotels/guest houses and Ilanga Estate? *

Yes

Registration Fee

Meals

Total Due

By submitting this Registration Form you are accepting liability for the payment of the outstanding fees. Should the fees be payable by your company of institution you will be responsible for ensuring that these are paid prior to the congress.