Booking Form

PHCSG Summer Conference Registration Form

'Patient Safety - who cares?!'

BCS PHCSG Summer Conference June 29^th - July 1^st 2009, Chesford Grange, Warwickshire

Mandatory fields are marked with an X

Title

First Name X

Surname X

Job Title
Organisation

Address	X
Postcode	X

Telephone	X	Fax
Email	X
Confirm Email	X

BCS Membership Number or Specialist Group Name if Claiming Members Rate:

Special requirements:

Where did you hear about the conference?:

Please tick this box if you are Speaking.

CONFERENCE FEES

Please tick this box if you are a BCS Member:

	BCS Member £ (Inc VAT)	Non-member £ (Inc VAT)
Monday June 29th - WELCOME EVENING BUFFET	20.00	20.00
Monday June 29th - ACCOMMODATION (B & B, En Suite)	115.00	115.00
Tuesday June 30th - DAY DELEGATE RATE	135.00	165.00
Tuesday June 30th - CONFERENCE DINNER (Smart / Casual)	45.00	45.00
Tuesday June 30th - ACCOMMODATION (B & B, En Suite)	115.00	115.00
Wednesday July 1st - DAY DELEGATE RATE	135.00	165.00
FULL CONFERENCE PACKAGE - Day delegate 30^th June, Conference dinner 30^th June, Accommodation 30^th June and Day delegate 1^st July	375.00	435.00
TOTAL:

We will invoice you for the amount shown.
Please enter a purchase order number:

If you wish to pay by Credit Card, please tick this box:

Data Protection Statement: I understand that my personal data will be used for the necessary purposes of running the conference.
In addition I agree to my data being used for the following: -
(i) inclusion in the delegate list and for conference related items
(ii) BCS, national and international initiatives in health informatics.
Please tick the box to enable your details to be used:

PLEASE NOTE THAT THIS BOOKING IS A CONTRACT. For cancellations received before 1^st May 2009, fees will be refunded subject
to an administrative charge of £35.00. Thereafter delegates are liable for the full booking fee but attendance may be substituted at any
time. All substitutions and cancellations must be notified in writing to PHCSG Administrator (see the address details below).

PHCSG, 54 New Street, Worcester WR1 2DL
Tel: +44 (0)1905 727461
Email: jill@phcsg.org

BCS VAT registration number: 618 1687 24