Expression of Interest - Puawaitahi, Starship Hospital and MEDSAC Paediatric Training Course on the Medical Assessment of Sexually Abused Children and Adolescents: 19-22 March 2019

Please read this form carefully.

The cost of registration for this course may be funded by the SAATS funders (directly to MEDSAC) if you are:

A New Zealand-based non-paediatrician clinician who does not have access to alternative funding mechanisms to attend; and
A current clinical practitioner aligned to a District Health Board SAAT service, or confirmed by a local Police district as participating in, or intending to commit to participate in, the local sexual assault roster.

Please submit your Expression of Interest and we will contact you.

Title :

First Name :

Last Name :

Email :

Phone :

Mobile Phone :

Address

Country :

Address :

City :

State or Province :

Zip or Postcode :

Clinical Position :

Special requirements (disability, dietary: please give details) : :

I agree to my name and contact details being circulated to other attendees for networking purposes (please tick one)

Yes

Registration Fees: Note: successful applicants for non-funded placements will receive a tax invoice for payment. This can be paid online by credit card or by internet banking. Paid-up MEDSAC membership (all types) is required in order to receive membership discounts.

Applications, and payment must be made by Friday 8 March 2019 unless an arrangement has been organised with the MEDSAC Education & Training Manager, Victoria Larbalestier victoria@medsac.org.nz.

A refund, less 10% administrative costs, will be given up to ten (10) working days before the course, should you be unable to attend. After this time, no refund will be given.

I wish to be assessed for a placement under the following category:

MEDSAC members All inclusive $1200

Non-MEDSAC members All inclusive $1450

Message :

If you are NOT an advanced trainee in general paediatrics:

Please supply, in the message box above, the details of the person recommending you for this course (name, position, workplace, email, phone - DDI, phone - mobile).

MEDSAC may seek verification from your local service to confirm its support of your application.

MEDSAC has the final say in applicant selection.

Completed forms must be received by MEDSAC office by Friday 8 March 2019.