Author: Charlotte Hannant

Booking Form for Parkinson’s Symposium
3rd November 2018

Full Name:

Address:

Postcode:

Tel No:

Mobile:

Email:

Dietary Requirements:

Workshops: Please choose 2 workshops from the selection below, clearly stating your first and second choice for each time slot. We will try to allocate you your first choice workshop but places are limited and will be allocated on a first come first served basis. You will be informed of which workshops you have been allocated on the event day.

Workshop title	First set of workshops running / 11.40 -12.20	Second set of workshops running / 13.20 -14.00
‘ To pee or not to pee’ looking after your bladder and bowels
Can Mindfulness Ease the Symptoms of Parkinson’s?
High Impact Exercise [restrictions apply]
Improving swallowing, speech, voice and communication
Carers matter too
‘Laughter is the Best Medicine’
Dance for Parkinson’s

Please complete payment details overleaf

Payment Details:

BACS transfer (Sort Code 30-92-59, A/C No. 03542470, Lloyds TSB, Irongate, Derby)
Cheque (made payable to University Hospitals of Derby and Burton NHS Foundation Trust and posted to NCORE at the below address)
Debit/Credit Card Payment (Please note there is a 1.5%charge on Credit Card transactions)

Please complete the following for Debit/Credit card payments

Debit Card

Credit Card

Visa/Mastercard

Name on Card

Expiry Date

Long Card No.

Amount

£

Security Code (Last 3 digits on your cards signature strip)

Signed

Booking forms to be returned by post to:
NCORE, Room 216, Junction 3, Level 3, London Road Community Hospital, London Road, Derby, DE1 2QY
or emailed to:
dhft.ncore@nhs.net

TERMS OF BOOKING & CANCELLATION: Substitution of delegates may be made at anytime, without cost, by writing to the organisers. Cancellations must be received in writing. A refund of the course fee will be made if you cancel your reservation SIX weeks prior to course start date. No refunds can be given after this date and you will be liable for full course fees. Full refunds will be given if the organisers cancel the course but the organisers are not responsible for any costs, other than course fees, which may be incurred by attendees. Information concerning your registration will be held on our database under the terms of the Data Protection Act 1998. The purpose for which this information is held is Direct Marketing, Education, Training and Administration. This information is not passed to third parties.
GDPR (General Data Protection Regulation)
Please can you confirm your consent for NCORE to keep in touch via email with information on new upcoming courses, special offers and relevant course information.
Please tick this box to confirm your consent