Title: Mr Mrs Miss Ms Other (Please Specify)

Title: Mr Mrs Miss Ms Other (please specify)

Surname/Family Name:

First/Given Name(s):

Gender: Male Female Date of Birth (DD / MM / YYYY):

Home Address:

Postcode:

Telephone Number: (Daytime) (Mobile)

E-mail:

Citizenship: UK citizen EU citizen Non-EU citizen

Nationality: Country of permanent residence:

What is your job title and/or profession?

Are you employed / self-employed? (please state)

Name & address of your organisation (if applicable):

Please describe your current work role and responsibilities:

What professional development are you hoping to gain from the conference?

Have you attended any previous group relations conferences? Yes No

If yes, please give name of conference/s and year/s:

How did you hear about the conference?

If you are currently a student on a Tavistock course, please indicate which course you are on:

D10 Other (state) Student number:

If you have previously been a student on a Tavistock course, please state which course (name/code) and date/s:

Do you have any special needs to enable you to participate fully in the conference?

Yes No

If yes, please indicate:

The conference fee is: £ 580 (Student fee)£650 (Non-student fee/External)

Who will be responsible for your fees? Yourself Your Sponsor

If you are a Tavistock student, please indicate if the fee is covered by your course

If you are an independent applicant then you may be eligible to apply for a reduced group fee:

If three people attend from the same organisation:£580 per member

If 4-6 people attend from the same organisation:£550 per member

If 7-8 people attend from the same organisation: £500 per member

Please use the online booking system to pay for your place

Cancellation Charges:

- Less than 2 weeks in advance of first day:100%

- Between 2-8 weeks in advance of first day:50%

- Between 8-12 weeks in advance of firstday: 25%

Print Name:

Signature: Date:

By returning this form to us, you consent to Tavistock Consulting processing data about you.

We would like to keep you informed about forthcoming events, programmes or conferences. Please tick this box if you would like to receive our email newsletter. ☐

Please note Course leads and Conference Directors reserve the right to withdraw membership, or not agree to membership of a given conference, if there is evidence that attendance might adversely affect the prospective conference member and / or the experience of other members within the conference, if they were to attend.

1