DEVELOPMENTS IN THE MANAGEMENTOF HEMIPLEGIA 2016
BOOKING FORM
Thursday 22 September 2016
Queen Alexandra College, Court Oak Rd, Birmingham, B17 9TG
DELEGATE 1First Name……………………………………………………………
Surname………………………………………………………......
Place of Work………………………………………………………......
Address 1………………………………………………………......
Address 2………………………………………………………......
Town………………………………………………………......
County………………………………………………………......
Postcode………………………………………………………......
Work Telephone Number………………………………………………………......
Email Address………………………………………………………......
Confirm Email Address…………………………………………………………….
GMC Number..……………………………………………………………
Special Dietary Requirements……………………………………………………………..
Do you have any additional requirements (wheelchair access, hearing loop etc)
………………………………………………………………………………………………………
DELEGATE 2First Name…………..…………………………………………………
Surname………………………………………………………......
Job Title/Occupation…………………………………………………………….
Work Telephone Number……………………………………………………………
Direct Line/Extension Number……………………………………………………………..
Email Address……………………………………………………………..
Confirm Email Address……………………………………………………………..
GMC Number……………………………………………………………..
Special Dietary Requirements…………………………………………………………….
Do you have any additional requirements (wheelchair access, hearing loop etc)
………………………………………………………………………………………………………
DELEGATE 3 First Name…………………………………………………………….
Surname………………………………………………………......
Job Title/Occupation…………………………………………………………….
Work Telephone Number……………………………………………………………
Direct Line/Extension Number……………………………………………………………..
Email Address……………………………………………………………..
Confirm Email Address……………………………………………………………..
GMC Number……………………………………………………………..
Special Dietary Requirements…………………………………………………………….
Do you have any additional requirements (wheelchair access, hearing loop etc)
………………………………………………………………………………………………………
DELEGATE 4 First Name…………………………………………………………….
Surname………………………………………………………......
Job Title/Occupation…………………………………………………………….
Work Telephone Number……………………………………………………………
Direct Line/Extension Number……………………………………………………………..
Email Address……………………………………………………………..
Confirm Email Address……………………………………………………………..
GMC Number……………………………………………………………..
Special Dietary Requirements…………………………………………………………….
Do you have any additional requirements (wheelchair access, hearing loop etc)
………………………………………………………………………………………………………
EARLY BIRD DISCOUNT for all bookings made BEFORE Friday 22nd July 2016 - £99.00.
STANDARD RATE for bookings made FROM Friday 22nd July 2016 onwards £129.00 (includes lunch).
STUDENT RATE of £25.00 applies at all times for any students in their final year of study.
CANCELLATION POLICY
A 100% refund will be given for cancellations received up to 30 days prior to the event date
A 75% refund will be given for cancellations received up to 14 days prior to the event date
A 25% refund will be given for cancellations received up to 7 days prior to the event date
Any cancellations received after this time will not receive a refund, but delegates are welcome to send a colleague in their place if they are unable to attend.
NB: STUDENT RATE IS NON-REFUNDABLE unless received up to 30 days prior to the event date
Should you need to cancel / amend your booking, please contact Samantha Lee - Events Programme Manager - - Tel 0345 120 3713.
Where did you hear about this event? (please tick)
□HemiHelp email
□HemiHelp website
□Work colleague
□COTs website
□Other
Please state ......
PAYMENT DETAILS
CHEQUES(make payable to HemiHelp) and send to Samantha Lee, HemiHelp, 6 Market Road, London, N7 9PW.
I enclose a cheque for£………………………………………………………………………..
DEBIT / CREDIT CARD
Please debit my Visa/ Mastercard* with the sum of £…………………………………………
Card number…………/…………/…………/………
Expiry date……/…… Security code …………
Name printed on card……………………………………………………………………………
INVOICES - IMPORTANT - Please ensure that you state the contact name and telephone number of the person / department responsible for any queries relating to your payment.
Please ensure that you ask your Accounts Department to add the DELEGATES' NAME AND DEPARTMENT on the Remittance Advice so that we can track your payment.
Please invoice: Name / Department:……………………………………………………………
Telephone Number: ......
Address: …………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………………………………………………..
the sum of £ ………………...... Ref / Purchase Order No: ………………………......
Signature…………………………………………… Date: ……………......
Are you a professional member of HemiHelp? YES ...... NO ......
Please complete and return with payment to
Samantha Lee, HemiHelp, 6 Market Road, London, N7 9PW