Scleroderma Qld AGM & Seminar Registration

Scleroderma Qld AGM & Seminar Registration

Saturday 26 October 2024

RBWH Education Centre & Videoconference

Bowen Bridge Rd &, Butterfield St, Herston QLD 4006

Registration starts 10 am
Lunch included

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState

Postcode

Phone Number

Area CodePhone Number

I'll be there*

Financial Member ($25)Non-Financial Member ($30)Video-conference (outside of SE Queensland - $10)Request sponsorship due to significant financial hardship

Payment Methods*

MAIL Please attach cheque or money order, payable to Scleroderma Assn. Of Qld Inc. 54 Avocado Lane, Maleny, QLD, 4552BANK TRANSFER Scleroderma Assoc of QLD - BSB:638-070 ACC: 7271069 REF: Your Name

Are you bringing a guest/s?*

YESNO

If yes, please provide their names

Please let us know for catering purposes of any dietary requirements.

VegetarianVeganCoeliacAllergies

Please provide additional details about your diet here.

THANK YOU

Once payment is received your registration will be confirmed.