FANZ Programme 2016 (Two Days) Registration FormPersonal DetailsFirst Name:       Surname:      

Organisation name: (if applicable)      

Full address:      

Phone: (inc area code)       Mobile Phone:      

Email address:      

Ethnicity: (Collected for funding purposes)      

Programme DetailsDate & Location of FANZ programme (click for drop down menu): -How did you hear about this programme? Website Facebook Autism New Zealand Staff Other

Programme Cost (per person)Please turn over for more details and important information.

$50.00 Family/Whānau

$175.00 Professional

Payment Details – GST number 64-234-382When completed, this registration form is your tax invoice. Please keep a copy for your records.

Amount Paid: $      Date Paid      

Cheque Please make cheques payable to ‘Autism New Zealand’

Visa / Mastercard

Card Number:      

Name on Card:      

Expiry: i.e.00/00      CCV Number: 3 digit on back of card

     

Direct Banking Account details: Autism New Zealand 03 0866 0356307 01Direct banking reference: FANZ, participant surname

Invoice

Please provide details of who to send the invoice to (i.e. accounts):

NamePhysical AddressEmail Address

1Autism New Zealand FANZ Registration Form: February 2016

FANZ Programme 2016 (Two Days)

Registration Form

Important InformationPayment: Payment must be made prior to the programme to confirm your place. We have various payment options available (cheque, credit card, direct banking and invoice)Programme Cancellation Policy: Cancellations must be sent in writing, (mailed or emailed), to Autism New Zealand. Cancellations received up to 30 days prior to the course date receive a full refund, less a 10% handling fee. Cancellations received less than 30 days and up to seven days prior to the course will receive a 50% refund. No refunds will be given for cancellations received within seven days of the course; however a substitute delegate may be nominated.Times: The programme runs from 9.30am – 3.30pm (both days) unless otherwise advised.(Maximum number: 25 people, minimum number: 10 people).Family/Whānau: Includes wider family members, caregivers and individuals with autism. Students (16+ years) are also welcome.

Registration: Confirmation of your registration will be on a first-booked and paid basis.

When completed, please return with payment to Autism New Zealand: Email: training@autismnz.org.nz,

Postal: PO Box 33481, Petone, Lower Hutt 5046 Fax: 04 803 3502, Ph: 04 803 3501. THANK YOU!

2Autism New Zealand FANZ Registration Form: February 2016