NIHR INVOLVE Conference 2010 Abstract Application Form

registration form


	Form Navigation Please use the TAB or Mouse to move to the next field All fields marked with an asterisk * MUST be completed. If you do not have a job title, organisation etc please enter NA When you have completed the form press the SUBMIT button. You will see a confirmation on the screen.

	1. Contact details

	First Name*

	Last Name*

	Job Title (if appropriate)*

	Organisation (if appropriate)*

	Address*




	Postcode*

	Telephone*

	Email*

	2. Please put an X in the box next to the one of the following that best describes you:


	Public (e.g. service user, carer)

	User researcher

	Researcher

	Research manager

	Voluntary sector

	Other (please describe

	3. Support and assistance requirements:

	Please tell us what we can do to make this conference accessible to you. For example, do you require a signer, a hearing loop or a personal assistant? Would you like information about this event in a different format? Should we reserve particular seating for you? Do you require a parking space close to the entrance of the venue? Do you require a quiet space for reflection?

	4. Dietary requirements:

	Do you have any specific dietary requirements or eating arrangements? If so, please specify:

	5. Evening meal:

	Are you coming to the evening meal (no extra charge) on 16th November:

	Yes

	No

	6. Help with costs:

	I would like help with costs from the conference fund

	Please give details of your request for help with costs



	If you are applying for help with costs you do not need to fill in Sections 7 and 8 below

	7. Conference registration fees:

	Please decide which of the three rates (community, not for profit or commercial) applies to your registration. The registration fees for these three rates are as follows: (Please tick the appropriate box):

Community		Not for profit		Commercial

	£110		£220		£330	Both days (no accommodation)

	£80		£140		£200	Day 1 only (includes evening meal)

	£80		£140		£200	Day 2 only

	Community	For local, voluntary and community organisations, small charities (with a yearly income under £150,000), self-help groups and individual members of the public)

	Not for profit	For national or statutory organisations (e.g. universities, NHS trusts, national charities)

	Commercial	For business organisations (e.g. pharmaceutical or medical devices companies, publishers)

	8. Payment
	(Please complete the amount and tick the appropriate box)

		Payment of £ will be made by a cheque made payable to "Professional Briefings Clients Account"

		Please send an invoice for £ to the following:



		Purchase order number (if required)

		Payment of £ will be made by electronic bank transfer to the following account:Professional Briefings BACS Account HSBC 95 Gloucester Road South Kensington London SW7 4SXSort Code: 40 06 19 Account no: 61240714

		I would like to pay by Mastercard/Visa card for the sum of £ I understand that I will be contacted by Professional Briefings to arrange payment by this method.


	*	I understand that a 20% administration charge will be applied to any cancellations notified in writing to Professional Briefings and acknowledged by them before 18th October 2010. After 18th October all registration fees must be paid in full.


		Please don't include my email address in the conference information pack.

		Please don't add my contact details to INVOLVE's mailing list.


	*	Tick this box when you are ready to submit your form


	The conference administration is being undertaken by Professional Briefings. For further information on any aspect of the conference please contact:

	Professional Briefings 37 Star Street Ware Hertfordshire SG12 7AA Telephone: 01920 487672 Email: london@profbriefings.co.uk