Course Application Form

Therapy Suite

Yellow Zone

Whiston Hospital

Warrington Road

Prescot

L35 5DR

0151 430 1015

Course Application Form

Please let us know if you are self-funding or externally funded by your employer / Trust. We will require payment prior to the course to secure your place. If you are externally funded and the funding is not released until you have attended the course and produced a receipt then we would suggest that you self-fund the course and claim the external funding back for your own reimbursement. We can provide you with necessary receipts of payment.

Please contact us directly on or if you think you will have any difficulty with funding, and we can discuss this personally. Thank you.

Please tick the courses that you are applying for:

Module 1: Introduction to the Bobath Concept: What is Normal Movement? –

Saturday 31st August & Sunday 1st Sept 2013: Venue: Whiston Hospital, Prescot Course fee £160

Module 2: The Assessment & Treatment of Adults with Neurological Conditions Part A – Course fee £160

Saturday 28th – Sunday 29th Sept 2013: Venue: Whiston Hospital, Prescot

Module 3: The Assessment & Treatment of Adults with Neurological Conditions Part B – Course fee £160

Saturday 26th – Sunday 29th October 2013: Venue: Whiston Hospital, Prescot

Discount of £30 for booking all 3 modules Total: £450 (instead of £480)

Please fill in your application form and send payment to the address above to secure your place, as soon as possible.

Total amount of payment £ ______

Please make cheques payable to: 5 Boroughs Partnership NHS Trust and send to Sue Grumley at the address above with this application form filled in. Thank you.

All Modules include light refreshments on Saturday and Sunday. Restaurant facilities available.

Please complete Name/Address in capital letters:

Name:______

Address:______

Telephone No:______Fax No:______

E-Mail:______

Current position and work involved:______


______

______

Profession: OT / PT______

HPC number: ______(Required)

Where did your hear about the course?:______

Map / travel details required? : Yes No

Receipt required? : Yes No

Accommodation details required?: Yes No

Any other comments or questions that you want us to help you with?: ______

______

______

Cancellation Policy & Fees:
Our cancellation terms are as follows: Notice must be provided in writing that you are cancelling your place on the course.
§  If you cancel over 10 working days before the course start date: full refund
§  5 – 10 working days before the course start date: 50% of fee is forfeited
§  Less than 5 working days before the course start date: full fee is forfeited
If you have any special circumstances that you wish to discuss with us, which may help with your attendance or cancellation of the course, please don’t hesitate to phone and talk with us.

Thank you for checking through the application form and taking care to fill it in. Please post to the above address now, with your payment, and we will be back in touch with you directly, to send you all the details and information you need about the courses. Thank you.

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