2012 workshop enrolment details

1. Shepherd Centre Workshops 2012

Please complete the following information to enrol.

Question Title

1. I would like to attend the workshop as a:

Parent(s)

Professional

What type of professional are you?

Question Title

2. Parent/Guardian/Professional name(s):

Question Title

3. Which Australian Hearing Branch have you attended?:

Question Title

4. Child's name:

Question Title

5. Child's date of birth:

Enter date

Date

Question Title

6. Relationship to child

Question Title

7. Name of any extra children who will attend:

Question Title

8. Date of birth of any extra children who will attend:

Question Title

9. Relationship to child(ren)

Question Title

10. Contact details

Address 1: *

Address 2:

City/Town: *

State/Province: *

ZIP/Postal Code: *

Country: *

Email Address:

Phone Number: *

Question Title

11. Better Start CRN Number? (if applicable):

Question Title

12. I would like to attend the following Shepherd Centre Workshop:

Annual Residential Workshop, Macquarie University/Courtyard by Marriot North Ryde (15-20 January)

Clan Lakeside Lodge, Terrigal (8-10 March)

Tocal College, Glenderra, Maitland (31 May-2 June)

Regional Workshop, Couchhouse Marina Resort, Batemans Bay (6-8 September)

Question Title

13. If you are currently living overseas and will be attending the workshop as an international guest, please indicate your payment preference below:

Cheque (payable to 'The Shepherd Centre')

Direct Deposit (The Shepherd Centre, BSB 032-003, Account 832829, with professional/child's name as reference)

Credit/Debit card (for Visa, Amex, Mastercard- please contact us on +61293517888 to make a payment)

I would like my child to be considered for sponsorship to this workshop

Question Title

14. Please indicate any special dietary requirements:

Question Title

15. Do you require accommodation?:

No thanks.

Yes.