COURSE BOOKING FORM Complete all sections of the form:- Photocopy for additional copies Please book me onto the following:- Title of Course: Male and Female Catheterisation (Competency Assessment) St Luke’s Hospice, Stamford Road, Turnchapel, PL9 9XA Date(s): Tuesday, 3rd October 2017 Course fee: £25.00pp 1.00-2.00pm 2.00-3.00pm 3.00-4.00pm Surname: Dr, Mr, Mrs, Miss, Ms Delete as appropriate First name: Place of work: Job title: Address for correspondence:- Postcode: Work telephone: Fax: e-mail: Home or mobile contact number: FULL DAY COURSES ONLY Please specify any special dietary requirements: – DO YOU HAVE ANY SPECIAL NEEDS? Please specify eg wheelchair access – WHO IS PAYING THE COURSE FEE? Myself Employer Other Please tick appropriate box (give details (give details below) below) Please give full details and address the invoice for the course fee should be sent:- Cheque for fee enclosed: Please make cheques payable to St Luke’s Tick if appropriate Hospice Plymouth Date: By signing this form you are also agreeing to our terms and conditions Signed: Return completed form to: St Luke’s Community Services, Education Department, Units 3-5, Brooklands, Budshead Road, Crownhill, Plymouth, PL6 5XR or email to Please ensure we have your correct contact details. Confirmation of a place will be sent via email.
COURSE BOOKING FORM Complete all sections of the form:- Photocopy for additional copies Please book me onto the following:- Title of Course: Male and Female Catheterisation (Competency Assessment) St Luke’s Hospice, Stamford Road, Turnchapel, PL9 9XA Date(s): Tuesday, 3rd October 2017 1.00-2.00pm 2.00-3.00pm 3.00-4.00pm Course fee: £25.00pp Surname: Dr, Mr, Mrs, Miss, Ms Delete as appropriate First name: Place of work: Job title: Address for correspondence:- Postcode: Work telephone: Fax: e-mail: Home or mobile contact number: FULL DAY COURSES ONLY – Please specify any special dietary requirements: DO YOU HAVE ANY SPECIAL NEEDS? – Please specify eg wheelchair access WHO IS PAYING THE COURSE FEE? Please tick appropriate box Myself Employer (give details below) Other (give details below) Please give full details and address the invoice for the course fee should be sent:- Cheque for fee enclosed: Tick if appropriate Please make cheques payable to St Luke’s Hospice Plymouth By signing this form you are also agreeing to our terms and conditions Signed: Date: Return completed form to: St Luke’s Community Services, Education Department, Units 3-5, Brooklands, Budshead Road, Crownhill, Plymouth, PL6 5XR or email to Please ensure we have your correct contact details. Confirmation of a place will be sent via email.
Catheterisation-Competency-Assessment-Booking-Form-031017.doc.docx