VITAL network meeting application form

Fight or flight to comfy and calm | Nerys Hughes

Please select which location you would like:

(either indicate yes or no or delete those that do not apply)

South Wales: Wednesday 2nd November 2016 10.30am – 3.30pm.

Gwent Visual Impairment Service, Brecon House, William Brown Close, Llantarnam Business Park, Llantarnam, Cwmbran, NP44 3AB

Leicester: Monday 28th November2016 10.30am – 3.30pm

New Parks House, Pindar Road, Leicester, LE3 9RN

London:Thursday 12th January201710.30am – 3.30pm.

RNIB, 105 Judd Street, London WC1H 9NE

Cost to attend: £40 per person including refreshments and lunch.

(Discounted rate of £30 for members of VIEW.)

This form contains 22 questions and should take around 5 minutes to complete.

Your details:

Please provide your personal details below. Type or write your answer at the end of each line.

  1. Surname:
  1. Title (Mr / Mrs / Ms / Miss / Dr /Other - please specify):
  1. Forename:
  1. Address including postcode:
  1. Address type: Home / work / other (please specify):
  1. Telephone (work):
  1. Telephone (home):
  1. Mobile telephone:
  1. Email address:
  1. Job title:
  1. Employer name:
  1. Are you a member of VIEW? Yes/No
  1. Invoice address if different (please include postcode):
  1. Invoice contact name:
  1. Invoice contact telephone number:
  1. Purchase order number (if required):

Individual requirements:

  1. Please state your preferred reading medium: standard print (Arial 14), large print, braille, audio CD, email:
  1. If large print, please state font size:
  1. Any dietary or access requirements? Please state Yes or No:
  1. If Yes, please specify:

Data protection:

Please answer the following questions yes or no:

  1. I am happy to receive emails from RNIB:
  2. I am happy to receive information on future training events:
  3. I am happy for my contact details to be shared with third parties:

Please send completed forms by email or post to:

Gray Robinson

RNIB Loughborough

Radmoor Road,
Loughborough

LE11 3ES

Telephone: 01509 632 413

Email

Bookings will be acknowledged within 5 days of receipt.

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