Online Workshop Registration Select a Workshop: 2012 Melbourne, Dr Bessel van der Kolk 2012 Sydney, Dr Bessel van der Kolk 2012 Brisbane, Dr Bessel van der Kolk 2011 Dialectical Behaviour Therapy (DBT) 2011 Eating Disorder Workshop Name: Address: City: State: Country: Postcode: Email Address: Confirm Email Address: Home/Work Telephone: Mobile Telephone: Occupation: Psychologist Psychiatrist Social Worker General Practitioner Counselor Nurse Dietician Nutritionist Physiotherapist Other Job Title: Organization: Billing and Mailing Address (if different from above) Additional Information:

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Make payable to Byron Clinic Remit To: Byron Clinic P/L   P.O. Box 2088   Byron Bay, NSW 2481   Australia	ANZ Bank 57 Jonson St Byron Bay, NSW 2481 Australia BSB Number: 012 554 Account Number: 4776 14421 Important: Please email us the bank transcript detail (if they are different to your registration last name and first name) so we can match your payment with your registration.	Visa or MasterCard only, please return to this workshops main page, scroll to the top of the page and open the "Credit Card and Fax Register" link. Print off a copy then complete your details and fax to Byron Clinic (02) 6680 9111 - thank you. You can register online but to pay by credit card you will need to fax us the details.

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Terms and Conditions: Please list one person per each registration form. Workshop places are limited and will be booked on a first come first served basis. A person is not registered for this workshop until the completed registration is received and workshop payment has been processed. The applicant is responsible for supplying clear and correct information; changes or additional contact may incur an admin fee. Applications will be processed according to the advertised conditions. A tax receipt and confirmation of your registration should be issued within 7 working days of receipt, via email. And you agree to contact Byron Clinic if you have not received notice within 7 working days. Tax receipts will be made out to the applicant unless otherwise stated. Requests for additional copies or changes to the attendance certificate or tax invoice will incur a $20 administration fee per item. Byron Clinic provides refreshments which include a selection of vegetarian and gluten free food, Byron Clinic does not cater for any other special diet requirements. Cancellations must be made in writing. A substitute may attend in your place; this will incur a $40 admin fee. Cancelation before close of standard registration will be reimbursed payment less an $80 cancelation and admin fee. No refunds will be made for cancelations after close of standard registration. Byron Clinic may offer to have your registration payment credited towards another Byron Clinic workshop; this will incur a $50 admin fee. Byron Clinic Pty Ltd reserves the right to make any changes to the above workshop without notice. In the event Byron Clinic Pty Ltd needs to cancel the workshop, then a full refund will be made. Byron Clinic Pty Ltd will not be responsible for any cost other than the workshop payment.

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