APPLICATION FORM
Female Genital Mutilation, Hands-on-Training course
(Limited to a maximum of 20 participants on a first come first serve basis)
Friday 26th May 2017 (08:30-17:00). The Clinical Education Centre (CEC) University Hospitals of North Midlands NHS Trust, Royal Stoke University Hospital, ST4 6QG
Registration Fee – Delete as appropriate
Early Bird (31st March 2017) / West Midlands Trainee - £125
Non West Midland Trainee / Non trainee - £150
Please read the following Information before completing this form
· The registration fee includes course materials, coffee, tea, lunch and admission to the lectures; you will receive confirmation of your registration within 14 days of receipt of your payment.
· Please note that you are not guaranteed a place until you receive this confirmation.
· If applying 14 days before the course, kindly telephone 01782 672302 to confirm that a place is available before sending your registration form and payment.
· On-site Parking is available as for other UHNM Visitors
Cancellation policy:
· Cancellation notice must be received in writing by Monday 15th May 2017 and accompanied by a copy of your registration form.
· An administration fee of £25 will be deducted.
· Cancellations received after this date will not be accepted under any circumstances and the candidate will forfeit the full course fee. However, you can substitute another colleague at any time
· In the unlikely event that the course is cancelled by CEC, we regret that we are unable to refund any delegate travel or accommodation costs or inherent cancellation or administration charges that have already been incurred by the delegate.
Please tick this box to say that you have read the above information
PERSONAL DETAILS (BLOCK LETTERS PLEASE)
Title (Mr/Mrs/Ms/Dr/etc)…………………………………………......
Forename(s)………………………………………………………………......
Surname………………………………………………………………………...... Hospital……………………………………………………………………………...... Job Title ………………………………………………………………………......
Address for Correspondence
House name / Number and street……………………………………………………………
Town……………………………………… County ……………………………………………….
Postcode ……………………………. Email address…………………………………………..
Contact number: ……………………………………………………………………………………
Special Dietary needs: ………………………………………………………………………….
PAYMENT DETAILS:
I enclose a cheque made payable to “University of North Midlands NHS Trust”
CREDIT/DEBIT CARD – To make a payment please call Nicola Antrobus on
01782 672302 (stating for FGM HoT Course for May 2017)
Please note that we cannot process your application unless full card details including security code and address at which the card is registered are provided
Signed ………………………………………………………….. Date ………………
PLEASE COMPLETE THE APPLICATION FORM AND RETURN WITH PAYMENT TO:
Nicola Antrobus-FGM Admin
Obs & Gynae Management Office
Ground Floor Maternity Building
Royal Stoke University Hospital
Newcastle Road
Stoke on Trent, ST4 6QG
Email:
Tele: 01782 672302