Post:RCSLT, 2 White Hart Yard, London, SE1 1NX

Reply slip

As places are strictly limited, please RSVP no later than 16 December 2016 to Lauren Longhurst:

Email:

Enquiries:0207 378 3029

Please book a place for me on the Dysphagia Research Priorities Workshop:

Name:

Address:

Town:

County:Postcode:

Telephone:

Email:

Job title (if appropriate):

Organisation (if appropriate):

Do you have any access requirements (e.g. bringing a carer, wheelchair access, communication support)?:

Dietary requirements: None VegetarianPescatarian Vegan

 Modified diet (please give detail):______

 Other (please state):______

Food allergies (please state):______

How would you prefer to be contacted about the workshop

 Email (If using a personal address, please note that communication may be filed in junk folder)

Post

Information about you

Please tick all that apply:

I have personal experience of dysphagia

I have cared/am caring for someone with dysphagia

I work with people with dysphagia

I do research into dysphagia

I am representing an organisation

Your experience

I have experience of dysphagia in:

Children

Adults with stroke or head injury

Adults with progressive neurological disorders such as dementia, Parkinson’s, Motor Neuron Disease

Head and neck cancer

Learning disabilities

Other (please specify):

Terms and Conditions

The workshop will include materials, lunch and refreshments. Travel expenses will be reimbursed by the RCSLT on completion of a ‘travel expenses’ form (sent to you upon receipt of the reply slip).

Cancellations: Please inform as soon as possible if you are no longer able to attend the workshop.

Your details will be included in a participant list, to be distributed to participants at this workshop only. If you would prefer not to be included, please indicate by placing a cross in the box [ ]

THE RCSLTWILL NOT PASS ON CONTACT DETAILS TO A THIRD PARTY NOT INVOLVED WITH THIS EVENT.