Plymouth Postgraduate Medical Centre

Derriford Hospital

Plymouth

PL6 8DH

Tel: 01752 792733

Email: or

Registration Form

Please complete all sections of this application form in block capitals

Title: ______(Dr/Mr/Miss/Mrs/Other)

Full name: ______

Address (for all correspondence):

______

E-mail Address: ______

Telephone (daytime/work): ______Telephone (evening/home): ______

Present post held: ______

GMC Reg. No: ______

Please indicate if you have any special Dietary Requirements ______

Please highlight the course you are applying for:

Core Ultrasound Intensive Care Course (CUSIC) Wednesday 1st February 2017 £150.00 YES/NO

Focused Echocardiography in the Critically Ill Thursday 2nd February 2017 £150.00 YES/NO

Both the above courses when booked together (1st February & 2nd February) £250.00 YES/NO

Please return the completed application form and cheque made payable to

“Plymouth Hospitals NHS Trust”

to:- Mrs Sue Coleman/Mrs Sandra Phillips

Specialty Training and Course Coordinators

Plymouth Postgraduate Medical Centre

Derriford Hospital

Plymouth

PL6 8DH

Alternatively; payment of the course fee can be made by debit/credit card over the telephone. Please ring the hospital cashier on Tel: 01752 439805 and quote account number TF 1104.

Please note – a total of 21 places are available on each course – they will be allocated in order of receipt of registration form with payment. Participants must attend for the whole duration of the course.

A cancellation fee of 20%will be charged for administration purposes up to 4 weeks prior to the start date of the course. 100% of the total fee will be charged if cancellation is within 4 weeks of the of the start date of the course, unless a substitute can be found to fill the vacancy or in exceptional circumstances.

Whilst we make every effort to run courses as advertised, we reserve the right to change the timetable and/or the teaching staff without prior notice and to cancel courses without liability (in which case there will be a full refund of course fees).

The information you provide will only be used to process your application and will be stored in accordance with the Data Protection Act 1998.