2013 Communication Skills Workshop Registration Survey

Welcome to the registration page for the Communication Skills Workshop, offered by the Australasian Chapter of Palliative Medicine of the Royal Australasian College of Physicians.

The workshop will be held in Sydney on 23-25 October 2013.

This form is to register your interest in attending. As numbers are limited and preference is given to trainees and Fellows of the Australasian Chapter of Palliative Medicine, your registration will be confirmed in the next few weeks. Please do not book any travel or accommodation until you receive confirmation of your enrolment via email.

The cost of the workshop, which will include reading material, lunch, and morning and afternoon tea, is $2053 +GST for a trainee and $3592 +GST for a Fellow. You will be sent an invoice after your registration is confirmed.

1.Please provide your name and position title:

Title

First name

Preferred name (if different from first name)

Last name

Position title

2.Please provide your affiliation and contact details below:

Department/section:

Hospital (where you anticipate to be employed at the time of the workshop):

Address 1:

Address 2:

City/Town:

State/Province:

ZIP/Postal Code:

Country:

Email Address:

Phone Number:

3.Are you currently enrolled in Palliative Medicine training at RACP?

Yes

If you answered "yes", please specify which year of training:

4.Are you currently enrolled in any other training at RACP?

Yes

If you answered "yes", please specify in which specialty:

5.Do you hold one or more RACP qualifications? (tick all those that apply)

6.Are you a consultant of staff specialist?

Yes

If you answered "yes", please specify in which area:

7.Are you working in, trained in or experienced in a specialty other than Palliative Medicine?

Yes

If you answered "yes", please specify in which specialty:

8.If you have any catering needs that we should be aware of, please list them below: