REGISTRATION FORM

I wish to register for the 19th MASCIP Conference
“STAGES AND AGES OF SPINAL CORD INJURY” on 23rd November 2017 at Burleigh Court, Loughborough.

Name:

Organisation/Place of work:

Job Title:

Address:

Postcode:

Telephone contact:

Email:

COSTS

I am a full member of MASCIP:
YES 100£NO 120£
I wish to pay by:
1. Cheque2. Internet3. Invoice (SCI Centres only)

1. Please make all cheques payable to: MASCIP and send to Lorraine Hedgecock, MASCIP Secretary, c/o Dot Tussler – Physio Lead, National Spinal Injuries Centre,
Stoke Mandeville Hospital, Aylesbury, Bucks HP21 8AL

2. Internet banking details will be sent to you upon receipt of this booking form.

3. Or please send me an invoice to (SCI Centres only):

Contact Name:
Address:
Postcode:
Email:

OTHER INFORMATION

Dietary Requirements: If you have any special dietary requirements,YES

Wheelchair Users: YES:
If yes, are you bringing a PA: YES
If bringing a PA then £10 charge to cover refreshments is required

We hold the information you supply us on our database and will use this information to supply information to where you have requested this. From time to time MASCIP may send you details concerning other spinal injury conferences, events or related information. By completing your email or telephone details and submitting this form, you will be indicating your consent to receiving marketing information from MASCIP unless you have indicated an objection to receiving such information by ticking the appropriate box: email Please note delegate fee is non-refundable.

BOOKING FORM AND PAYMENT DUE BY 31st OCTOBER 2017

Δ