Dear .......... - UCT Faculty of Humanities · Web viewFri, 21 Nov. 11h45. Registration and...
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Class of 1974 Reunion: 21-23 November 2014 REGISTRATION FORM Please complete this form and return it with your payment, by not later than 17 OCTOBER 2014 and return to: Joan Tuff, Alumni & Bequest Officer, UCT Faculty of Health Sciences, Anzio Road, Observatory, 7925. Telephone: +27 (0)21 406 6686, Fax: +27 (0)21 650 5010 or +27 (0)86 612 6390, Email: [email protected] Your details Name: Address: Email Telephone/mobile numbers: Your payment South African Rands please Tick your preferred payment method 1. cheque (payable to “UCT”) 2. direct (EFT) deposits Bank: Standard Bank of South Africa, Rondebosch Account name: UCT Sundries Account Branch Code: 025009 Account Number: 071 503 854 Type of Account: Current Reference: 1974surname120098 eg 1974adams120098 3. internet banking Same as direct deposits Swift code SBZAZAJJ (foreign payments) – please include bank charges with your payment For payment methods 2 or 3, forward a copy of your deposit slip by fax or email to Joan Tuff Fax +27 (0) 650 5010 or +27 (0)86 612 6390 or Email: [email protected]
Transcript of Dear .......... - UCT Faculty of Humanities · Web viewFri, 21 Nov. 11h45. Registration and...
Class of 1974 Reunion: 21-23 November 2014
REGISTRATION FORMPlease complete this form and return it with your payment, by not later than 17 OCTOBER 2014 and return to:Joan Tuff, Alumni & Bequest Officer, UCT Faculty of Health Sciences, Anzio Road, Observatory, 7925.Telephone: +27 (0)21 406 6686, Fax: +27 (0)21 650 5010 or +27 (0)86 612 6390, Email: [email protected]
Your detailsName:
Address:
Email Telephone/mobile numbers:
Your payment South African Rands please Tick your preferred payment method
1. cheque (payable to “UCT”)
2. direct (EFT) depositsBank: Standard Bank of South Africa, RondeboschAccount name: UCT Sundries AccountBranch Code: 025009 Account Number: 071 503 854Type of Account: CurrentReference: 1974surname120098 eg 1974adams120098
3. internet banking Same as direct deposits Swift code SBZAZAJJ (foreign payments) – please include bank charges with your payment
For payment methods 2 or 3, forward a copy of your deposit slip by fax or email to Joan TuffFax +27 (0) 650 5010 or +27 (0)86 612 6390 or Email: [email protected]
4. credit card Authority for payment by CREDIT CARD to the University of Cape TownPlease debit my American Express MasterCard Visa Other:
Amount:
Card number
Last three digits on back:
Expiry date:
Class of 1974Today’s date:
Signature: …………………………………….
Programme
Fri, 21 Nov 11h45 Registration and Lunch, MAC Club, Medical School13h15 Tour of Medical School15h00 Tour of the Heart of Cape Town Museum, Groote Schuur Hospital18h00 Cocktail party – Institute of Infectious Disease & Molecular Medicine
(IDM) building, Medical School Dress: Smart Casual
Sat, 22 Nov 8h00-12h30 Academic Meeting – Wolfson Pavilion Lecture Theatre, IDM Building12h45 Lunch – foyer, IDM BuildingAfternoon At leisure18h30 for 19h00
Class photograph followed by Gala Dinner – Fuller Hall dining roomDress: Jacket & Tie/Suit
Sun, 23 Nov
06h30 & 8h30 Medical 10 Race or mountain walk with Tim and Barry
10h30 Guided tour of Kirstenbosch Gardens12h00 Family Picnic – Kirstenbosch Gardens
Costs
Date Event Cost Number attending
Total
Friday,21 November
Registration (obligatory; per class member only)
R700.00 per classmate
R700.00
Lunch – Mac Club R120.00 per person
Heart of Cape Town Museum, Groote Schuur Hospital
R50.00 per person
Cocktail Party - Foyer, IDM Building R140.00 per person
Saturday,22 November
Academic meeting – Wolfson Pavilion, IDM Building
No charge
Light Lunch – Foyer, IDM Building R120.00 per person
Gala Dinner – Fuller Hall dining room R320.00 per person
Sunday,23 November
*Guided Tour of Kirstenbosch Gardens R45.00 per person
*Picnic - Kirstenbosch Gardens - With ½ bottle of red or white wine (circle) Without wine
R185.00 per person
R155.00 per
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Class of 1974
person* Entrance fee for your own account on the day
TOTAL PACKAGE (per class member): R1680.00 + Spouse / Partner R 980.00 =
R2660.00
Please note: In the event of a cancellation, a cancellation fee will be levied. Refunds may only be accommodated if confirmations for expenses such as catering, printing, photography, etc have not yet been made. Your understanding would be greatly appreciated.
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Class of 1974
Name tags
Classmate Partner
Name and Surname Name and Surname
Dietary preferences/allergies:
Walking disabilities:
Academic Meeting:
We need two more speakers - would you like to speak for 15 minutes of a topic of your choice?
If yes, title of your talk:
Audio-visual equipment required (specify):
The following class members have agreed to speak:Ivan Schewitz Pectus Excavatum. The Nuss ProcedureBrian Warren Surgical Practice in a Litigation-Prone SocietyDavid Franklin Life After Medicine?Ted Sommerville Learning from TeachingDonald Miller Investing is an Incurable DiseaseDenis Brown GP: SA vs GBHaggis Black Camera and Stethoscope – 40 Years in a Rural PracticePeter Beresford Establishing a culture of patient safety
Mountain Walk: Would you like to join Tim and Barry on a mountain walk?
Yes No If yes, number attending
OR
Medical 10 Race
Would you like to participate?
Yes No
Names of classmates who have indicated that they would like to attend thus far:Beverley Adriaans, Brynne Ascott-Evans, Peter Beresford, Haggis Black, Peter Bonafede, Denis Brown, Bruce Castle, Peter Chapman, Kathleen Commerford, Arnold Di Bella, Robin Emsley, David Franklin, Ian Gilbertson, Rhodiah Gool, Christopher Harrison, Patricia Hawke, Faika Jappie, Norman Marcus, Harold Marcus, Stuart Meintjies, Donald Miller, Dirk Mouton, Tim Noakes, Andreas Obholzer, Olaf Opitz, Charles Palmer, Shafik Parker, Barry Penn, Jeffrey Perlman, Paul Potter, Ivan Schewitz, Peter Schwartz, David Shlugman, Ted Sommerville, Rosalind Wainwright, Brian Warren, Bernard Werner.
Booklet forms received thus far - DEADLINE 17 OCTOBER (questionnaire on page 4)Beverley Adriaans, Brynne Ascott-Evans, Peter Beresford, Denis Brown, Peter Chapman, Kathleen Commerford, Arnold Di Bella, Robin Emsley, David Franklin, Ian Gilbertson, Rhodiah Gool, Christopher Harrison, Patricia Hawke, Donald Miller, Dirk Mouton, Andreas Obholzer, Olaf Opitz, Charles Palmer, Barry Penn, David Roy, Ivan Schewitz, Peter Schwartz, David Shlugman, Ted Sommerville, Manfred Teichler, Rosalind Wainwright, Brian Warren, Bernard Werner.
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Class of 1974
CLASS OF 1974
The Reunion Booklet – IF NOT ALREADY COMPLETED
Please complete this part whether you are attending the reunion or not. Fill in the table below by TYPING in each answer. Be brief and include an ID size photograph as an attachment. Save the form as a word document, not a PDF, so that it can be copied and pasted into the booklet.
The completed form should be no longer than one page. Please note that you do not have to hit enter when filling in the form; the spacing will adjust automatically at the end of each line, therefore just click in each blank cell and type the individual answer. Please do not move or adjust the table or change the pre-set fonts.
NameHome address
Code & countryTelephone (home)
FaxTelephone (work)
FaxMobileEmail
Place of employment (if now retired, state last
position held)Field of Practice
Actual Job DescriptionDegrees (post grad)What have you been
doing since you graduated?
Tell us about your wife/partner, children
and grandchildrenHobbies, interests and
sportsAchievements/Awards
Life’s memorable moments
Would you have any objection to this information being published in a UCT publication? YES NO(we will not divulge your contact details)
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