Registration Form - Amputee Rehab Course

BSRM SIGAM 16th Advanced Prosthetic and Amputee Rehabilitation Course - 14-16 March 2016 at Royal National Orthopaedic Hospital, Stanmore, Middlesex Registration Form

Name: GMC number (for those requiring medical CPD credits) Title and current post: Address:

Phone: Email:

COURSE FEES (includes coffee, lunch, tea and course notes) Three-Day Rate £315 £ OR

14 March 2016 £120 £ Amputation Rehabilitation – general topics 15 March 2016 £120 £ Lower limb prosthetics

16 March 2016 £120 £ Upper limb prosthetics and CLD

Dinner – 14 March 2016 Free Yes / No (Optional)

Non BSRM Members Supplement £40 £ (waived for non-medics) £ TOTALS:

Please see attached list for suggestions re accommodation in the location

Details of any special needs ..………………………………………….………………………………………………………………………………………. (eg mobility, dietary) NB: The BSRM will do its best to accommodate these if notified in advance. Special diets cannot be catered for without prior notification, this includes vegetarian diets.

I enclose payment of: £ ...... (payable to BSRM) for card payment see overleaf

Note: A cancellation fee of 15% applies to cancellations received prior to 14 February 2016. We regret that no refunds can be made after 14 February, however substitutions will be accepted.

Signed: ...... Date: ………………………….

Please make cheques payable to: British Society of Rehabilitation Medicine. Please return this form and payment to: Mrs Sandy Weatherhead, British Society of Rehabilitation Medicine, C/o Royal College of Physicians, 11 St Andrews Place, London NW1 4LE (tel: 01992 638865 fax: 01992 638674)

We are able to accept payment by cheque (payable to BSRM), Card (Mastercard, Visa or Switch - sorry not Amex) , PayPal to [email protected], or bank transfer. Payment must be in £sterling

Total Amount Due £

 I enclose a cheque payable to BSRM  I have transferred the total amount due direct to the BSRM Account below Royal Bank of Scotland, Dundee Chief Office – Sort Code: 83-50-00 Account Name: British Society of Rehabilitation Medicine Account Number: 00701914 Please include the delegate’s name followed by Bristol 2014 or your invoice number as a reference.  I have made a payment via PayPal using the following reference ______

 I authorise you to debit my Mastercard*/ VISA*/ Switch* Expiry Date   * please delete as appropriate m m y y

 Card number    

Last 3 digits on signature strip  Switch cards only

Issue number  Valid from date   m m y y

Name and address of card holder if different from that on front of this form:

Name: ______

Address: ______

______

Signature: ______Date: ______

Please do not email full card details – this presents a security risk to you – You may telephone with these OR Please invoice Title: Forename: Surname:

Position: Purchase Order No:

Address:

Postcode: