5th ASIA PACIFIC

OCCUPATIONAL THERAPY CONGRESS

19~24 NOVEMBER 2011 ● CHIANG MAI THAILAND
FAX TO: (66) 2 943 4149
Registration Online : www. APOTC2011.ORG

REGISTRATION FORM
Form A – REGISTRATION
Delegate Information
Please complete this in BLOCK CAPITALS. Photocopy of this form is acceptable
Title: ( please tick √ )  Prof.  Dr.  Mr.  Mrs.  Ms.

Last Name/ Surname: First Name(S) : __

Company/Organization: _______ Department/Unit: ________________

Designation: ______________________________________________________________________________

Mailing Address: __________________________________

Postal Code/Zip: _____________________ City: ____________ Country: ____________________________

Telephone: ( ) Fax: ( ) E-mail: ____

Nationality:

First time attending delegate Regular attending delegate

Food preference: Muslim Halal  Vegetarian  Standard Food 

Accessibility: __________________________________ ___________

Accompanying persons:

Last Name/Surname: First Name(s): __

Last Name/Surname: First Name(s): __

Food preference: Muslim Halal  Vegetarian  Standard Food 

Accessibility: __________________________________ ___________

Please send me an invitation letter for Visa purpose

Registration Fee

Categories On or Before 30.09.2011 After 30.09.2011 Amount $

Delegates
 US$ 360  US$ 450

Students
 US$ 200  US$ 250

Total (1)

The Registration Fees includes:

Full attendance at Sessions from 21 to 24 November, 2011 unless otherwise stated, Congress documents, including bag, final program ,
Please complete this form & return to the Conference Secretariat c/o GAT MICE
Mail: 19/117 Soi Kubon 28,Kubon Rd., Kannayaow, Kannayaow, Bangkok, Thailand 10230
Tel: (66) 2 509 2276 Fax: (66) 2 943 4149 Email: secretariat @apotc2011.com
(2) Coffee Break, (1) Lunch, Access to exhibition, Final list of participants, Welcome Reception, tourist documentation in Chiang Mai.

Workshop and Clinical Visit Registration

Program Date Price
PRPP strategy training [code: ws01] 20 November 2011 US$ 60
Max: 30 (AM)
Sensory Processing Disorder [code: ws02] 20 November 2011 US$ 60
Max: 30 (AM)
Thai dancing: Enabling Motor Planning [code: ws03] 20 November 2011 US$ 60
Max: 30 (AM)
Assistive technology, Home modification and environmental adaptation: 20 November 2011 US$ 120
Eastern versus Western Contexts [code: ws04] (PM)
Max: 30
Elephant-assisted therapy for children with autism[code: ws05] 20 November 2011 US$ 120
Max: 40 (PM)
Meditation: Enhancing Spiritual Well-being [code: ws06] 20 November 2011 US$ 60
Max: 30 (PM)
Health Yoga: Application in Occupational Therapy [code: ws07] 20 November 2011 US$ 60
Max: 30 (PM)
Forensic Occupational Therapy [code: ws08] 20 November 2011 US$ 60
Max: 30 (PM)
Wat Huay Kieng (Rehabilitation Center in community) [code: cv01a] 20 November 2011 US$ 30
Max: 30
Suanprung Psychiatric Hospital [code: cv01b] 20 November 2011 US$ 30
Max: 30
Rajchanakarind Child Development Center [code: cv02] 20 November 2011 US$ 30
Max: 30
Piyamal Elderly Service Center [code: cv03] 20 November 2011 US$ 30
Max: 30

Please confirm your participation for the following events

Program Date Price
 Full-Day Education Symposium 19 November 2011 Free of Charge
 Welcome Reception 21 November 2011 Free of Charge
Gala Banquet 23 November 2011 US$ 75

Total – Registration & Events: US$

Cancellation Policy
All refund requests must be notified in writing to the Conference Secretariat and be received by 31 August 2011, an administration fee
of US$ 100 would be charged. There will not be any refund after 31 August 2011

Please complete this form & return to the Conference Secretariat c/o GAT MICE
Mail: 19/117 Soi Kubon 28,Kubon Rd., Kannayaow, Kannayaow, Bangkok, Thailand 10230
Tel: (66) 2 509 2276 Fax: (66) 2 943 4149 Email: secretariat @apotc2011.com
 Please complete this form & return to the Conference Secretariat c/o GAT MICE
Mail: 19/117 Soi Kubon 28,Kubon Rd., Kannayaow, Kannayaow, Bangkok, Thailand 10230
Tel: (66) 2 509 2276 Fax: (66) 2 943 4149 Email: secretariat @apotc2011.com