VITAL network meeting application form
Fight or flight to comfy and calm | Nerys Hughes
Please select which location you would like:
(either indicate yes or no or delete those that do not apply)
South Wales: Wednesday 2nd November 2016 10.30am – 3.30pm.
Gwent Visual Impairment Service, Brecon House, William Brown Close, Llantarnam Business Park, Llantarnam, Cwmbran, NP44 3AB
Leicester: Monday 28th November2016 10.30am – 3.30pm
New Parks House, Pindar Road, Leicester, LE3 9RN
London:Thursday 12th January201710.30am – 3.30pm.
RNIB, 105 Judd Street, London WC1H 9NE
Cost to attend: £40 per person including refreshments and lunch.
(Discounted rate of £30 for members of VIEW.)
This form contains 22 questions and should take around 5 minutes to complete.
Your details:
Please provide your personal details below. Type or write your answer at the end of each line.
- Surname:
- Title (Mr / Mrs / Ms / Miss / Dr /Other - please specify):
- Forename:
- Address including postcode:
- Address type: Home / work / other (please specify):
- Telephone (work):
- Telephone (home):
- Mobile telephone:
- Email address:
- Job title:
- Employer name:
- Are you a member of VIEW? Yes/No
- Invoice address if different (please include postcode):
- Invoice contact name:
- Invoice contact telephone number:
- Purchase order number (if required):
Individual requirements:
- Please state your preferred reading medium: standard print (Arial 14), large print, braille, audio CD, email:
- If large print, please state font size:
- Any dietary or access requirements? Please state Yes or No:
- If Yes, please specify:
Data protection:
Please answer the following questions yes or no:
- I am happy to receive emails from RNIB:
- I am happy to receive information on future training events:
- I am happy for my contact details to be shared with third parties:
Please send completed forms by email or post to:
Gray Robinson
RNIB Loughborough
Radmoor Road,
Loughborough
LE11 3ES
Telephone: 01509 632 413
Bookings will be acknowledged within 5 days of receipt.
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