Locked in Syndrome Study Day - Registration form Delegate fee (£120) Title: . First Name: Surname: Job Title: Organisation: Address: Postcode: Telephone: Mobile: Email: Special dietary or other requirements: Please add me to the mailing list to receive information about future RHN training events PAYMENT METHOD (Please tick your chosen method) Cheque: Payable to The Royal Hospital for Neuro-disability and send for the attention of Phili Denning Credit/Debit Card: We accept debit and credit card payments; please contact 020 8780 5141 or Ext. 5140 to pay securely over the phone. Invoice: PO or other reference number: Invoicing address: Accounts payable contact email: Accounts payable contact tel: BACS Please send to the following Natwest Bank, RHN General Account ☐ Sort code Account no. Please send your BACS remittance form as confirmation of payment. Your BACS reference: If you are not self-funding please confirm who has authorized your attendance at this course and the funding: Name: Position: Contact email: Tel: Please return this form (one per applicant) to Phili Denning, Academic Event Manager at or by post: – Royal Hospital for Neuro-disability, West Hill, Putney, London SW15 3SW United Kingdom Venue: Royal Hospital for Neuro-disability, London. Conference fees include refreshments and lunch Cancellations/refunds: A refund, less 20% administration fee will be made if cancellations are received in writing at least 4 weeks before the course. We regret that refunds cannot be made for cancellation or non-attendance after this time. Substitute attendees are welcome at any time.
Locked in Syndrome Study Day - Registration form Delegate fee (£120) Title: . First Name: Surname: Job Title: Organisation: Address: Postcode: Telephone: Mobile: Email: Special dietary or other requirements: Please add me to the mailing list to receive information about future RHN training events PAYMENT METHOD (Please tick your chosen method) Cheque: Payable to The Royal Hospital for Neuro-disability and send for the attention of Phili Denning Credit/Debit Card: We accept debit and credit card payments; please contact 020 8780 5141 or Ext. 5140 to pay securely over the phone. Invoice: PO or other reference number: Invoicing address: Accounts payable contact email: Accounts payable contact tel: ☐ BACS Please send to the following Natwest Bank, RHN General Account Sort code Account no. Please send your BACS remittance form as confirmation of payment. Your BACS reference: If you are not self-funding please confirm who has authorized your attendance at this course and the funding: Name: Position: Contact email: Tel: Please return this form (one per applicant) to Phili Denning, Academic Event Manager at – or by post: Royal Hospital for Neuro-disability, West Hill, Putney, London SW15 3SW United Kingdom Venue: Royal Hospital for Neuro-disability, London. Conference fees include refreshments and lunch Cancellations/refunds: A refund, less 20% administration fee will be made if cancellations are received in writing at least 4 weeks before the course. We regret that refunds cannot be made for cancellation or non-attendance after this time. Substitute attendees are welcome at any time.