britishirishmeningiomasociety.files.wordpress.com…  · Web viewI wish to attend the Second BIMS...

3
Registration Form Second Annual Meningioma Symposium Saturday 13 th May 2017 09.00-17.00 HQS Wellington, Temple Stairs, Embankment, LONDON WC2R 2PN Please complete the form in block capitals; Title: Initials: Surname: Hospital/Institute: Grade: Email Address (for correspondence): Home Address (including postcode): Booking Requirements; I wish to attend the Second BIMS symposium and I enclose the registration fee : Tick Consultant - £100 ☐ OR Trainee / Nurse / AHP /Medical Student - £60 ☐ I am a surgical trainee and I wish to attend the Case-based Meningioma Forum with Prof Michael McDermott, UCSF 16.00 Friday 12 th May, Sir Alexander Fleming Building

Transcript of britishirishmeningiomasociety.files.wordpress.com…  · Web viewI wish to attend the Second BIMS...

Page 1: britishirishmeningiomasociety.files.wordpress.com…  · Web viewI wish to attend the Second BIMS symposium and I enclose the registration fee : Tick. Consultant - £100 ☐ OR ...

Registration Form

Second Annual Meningioma Symposium

Saturday 13th May 2017 09.00-17.00

HQS Wellington, Temple Stairs, Embankment, LONDON WC2R 2PN

Please complete the form in block capitals;

Title: Initials: Surname:

Hospital/Institute:

Grade:

Email Address (for correspondence):

Home Address (including postcode):

Booking Requirements;

I wish to attend the Second BIMS symposium and I enclose the registration fee : Tick Consultant - £100 ☐

OR Trainee / Nurse / AHP /Medical Student - £60 ☐

I am a surgical trainee and I wish to attend the

Case-based Meningioma Forum with Prof Michael McDermott, UCSF16.00 Friday 12th May, Sir Alexander Fleming Building

(Room 158D, MDL1, Bay D) Imperial College, Prince Consort Rd, SW7 2BB

40 places – first come, first served No fee ☐

Page 2: britishirishmeningiomasociety.files.wordpress.com…  · Web viewI wish to attend the Second BIMS symposium and I enclose the registration fee : Tick. Consultant - £100 ☐ OR ...

I wish to attend the pre-symposium dinner Sea Containers Restaurant, 20 Upper Ground, LONDON SE1 9PD

20.00 Friday 12th May 2017

Dietary requirements : Dinner £60 ☐

Total payment enclosed :

Payment details;

Terms and Conditions;

Bookings are accepted on a first come, first served basis. Confirmation of a place will be sent by email within 14 days of payment being received. All cancellation requests on or prior to 13th April 2017 must be made in writing and emailed to Louise.Nicholas@bhrhospitals .nhs.uk on receipt of which a full refund will be given minus a £20 administration charge. No refunds will be permitted after 13th April 2017. The Trust will not be responsible for any loss or damage to personal property whilst attending the event. The Trust reserves the right to cancel bookings without notice, in these extreme circumstances full refunds will be given. Please return this form with payment to: Louise Nicholas, Education Centre, Ground Floor,

Rom Valley Way, Romford, Essex, RM7 0AG or email it to Louise.Nicholas@bhrhospitals .nhs.uk

For all event queries please contact : [email protected]

Registration Fee Enclosed: Cheque: ☐ Card Payment: ☐

Card Number: Expiry Date:

Security Number: Card Type: VISA ☐ MASTERCARD ☐SWITCH ☐

Start Date: Issue Number:

Please note - All cards must be registered to the person applying for the course. American express is not accepted. Cash is not accepted. Cheques to be made payable to Barking, Havering and Redbridge University Hospitals NHS Trust.

£

mailto:[email protected]
mailto:Louise.Nicholas@bhrhospitals
mailto:Louise.Nicholas@bhrhospitals

07 Medical Assessment Adult - fimmccall.com · 3 MEDICAL HISTORY (cont…) ☐ ☐ Skin Cancer ☐ ☐ Other þ = Past Condition þ = Ongoing Condition ☐ ☐ Autism ☐ ☐ Mild

07 Medical Assessment Adult - fimmccall.com · 3 MEDICAL HISTORY (cont…) ☐ ☐ Skin Cancer ☐ ☐ Other þ = Past Condition þ = Ongoing Condition ☐ ☐ Autism ☐ ☐ Mild

Registration Checklist 1 Grade · ☐Korean (203) ☐Filipino (400) ☐Samoan (303) ☐Vietnamese (204) ☐Hmong (208) ☐Tahitian (304) ☐Asian Indian (205) ☐Other Asian (299)

Registration Checklist 1 Grade · ☐Korean (203) ☐Filipino (400) ☐Samoan (303) ☐Vietnamese (204) ☐Hmong (208) ☐Tahitian (304) ☐Asian Indian (205) ☐Other Asian (299)

2019/20 Membership Application Form · ☐Catering ☐Event Management Companies ☐Event Support Services ☐Venues ☐Inbound Tour Operators ☐Tour Desks ☐Travel Agents ☐Wholesale

2019/20 Membership Application Form · ☐Catering ☐Event Management Companies ☐Event Support Services ☐Venues ☐Inbound Tour Operators ☐Tour Desks ☐Travel Agents ☐Wholesale

The complete RSPB pin badge range€¦ · ☐ orca ☐ osprey 1 ☐ osprey 2 ☐ osprey 3 (silver) ☐ osprey 5 ☐ otter 1 ☐ oystercatcher 1 ☐ oystercatcher 2 ☐ peacock butterfly

The complete RSPB pin badge range€¦ · ☐ orca ☐ osprey 1 ☐ osprey 2 ☐ osprey 3 (silver) ☐ osprey 5 ☐ otter 1 ☐ oystercatcher 1 ☐ oystercatcher 2 ☐ peacock butterfly

Name: CERT Level · ☐First Aid ☐CPR / AED ☐Wilderness 1st Aid ☐EMR ☐EMT ☐Disaster Services ☐Shelter Fundamentals ☐Psychological 1st Aid ☐Pet 1st Aid ☐Food Handling

Name: CERT Level · ☐First Aid ☐CPR / AED ☐Wilderness 1st Aid ☐EMR ☐EMT ☐Disaster Services ☐Shelter Fundamentals ☐Psychological 1st Aid ☐Pet 1st Aid ☐Food Handling

Lenze 8400 BaseLine Inverter Drives - ValinOnline.com · GOST-R Degreeofprotection EN605292) IP20 NEMA250 Type1 ... Inverter E84AV☐☐☐1124☐☐0 E84AV☐☐☐1524☐☐0 E84AV☐☐☐2224☐☐0

Lenze 8400 BaseLine Inverter Drives - ValinOnline.com · GOST-R Degreeofprotection EN605292) IP20 NEMA250 Type1 ... Inverter E84AV☐☐☐1124☐☐0 E84AV☐☐☐1524☐☐0 E84AV☐☐☐2224☐☐0

St. Benedict’s Presents A NEW Extended Day Academic ... · ☐Yes ☐ ☐ ☐ ☐Yes ☐ ☐ ☐Math ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Ma ☐ LE. 3 . Child Registration Form

St. Benedict’s Presents A NEW Extended Day Academic ... · ☐Yes ☐ ☐ ☐ ☐Yes ☐ ☐ ☐Math ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Ma ☐ LE. 3 . Child Registration Form

ADMINISTRATIVE · 851 30th Avenue SE | Rochester MN 55904 | 507-280-3157 Registration Form Registration Deadline is 4/1/2020 ☐ ☐ ☐ ☐ ☐ ☐

ADMINISTRATIVE · 851 30th Avenue SE | Rochester MN 55904 | 507-280-3157 Registration Form Registration Deadline is 4/1/2020 ☐ ☐ ☐ ☐ ☐ ☐

HEAD SHOT HERE - hemophilia.ca · Poison Ivy ☐ Insect Bites ☐ Peanuts ☐ Penicillin ☐ Animals ☐ Food ☐ Drugs ☐ Other ☐ _ _ _ _ 3. Epipen or Anakit Does he/she have

HEAD SHOT HERE - hemophilia.ca · Poison Ivy ☐ Insect Bites ☐ Peanuts ☐ Penicillin ☐ Animals ☐ Food ☐ Drugs ☐ Other ☐ _ _ _ _ 3. Epipen or Anakit Does he/she have

Distribution Mgmt BIMS

Distribution Mgmt BIMS

CUSC-CCREU · eval3 concern shown by the university for you as an individual ☐ ☐ ☐ ☐ eval9 your decision to attend this university ☐ ☐ ☐ ☐ eval12 Would you recommend

CUSC-CCREU · eval3 concern shown by the university for you as an individual ☐ ☐ ☐ ☐ eval9 your decision to attend this university ☐ ☐ ☐ ☐ eval12 Would you recommend

Sight Words Second Grade - funwithmama.com · Second Grade Sight Words Checklist ☐always ☐around ☐because ☐been ☐before ☐best ☐both ☐buy ☐call ☐cold ☐does ☐don’t

Sight Words Second Grade - funwithmama.com · Second Grade Sight Words Checklist ☐always ☐around ☐because ☐been ☐before ☐best ☐both ☐buy ☐call ☐cold ☐does ☐don’t

BIMS Partner_Guide_2011_Edition

BIMS Partner_Guide_2011_Edition

GROCERY LIST - Bodybuilding.com...GROCERY LIST PROTEIN ☐ Chicken Breast ☐ Turkey Breast ☐ Cod ☐ Tilapia ☐ Pollok ☐ Low-fat steak (one meal per day) ☐ Salmon (one meal

GROCERY LIST - Bodybuilding.com...GROCERY LIST PROTEIN ☐ Chicken Breast ☐ Turkey Breast ☐ Cod ☐ Tilapia ☐ Pollok ☐ Low-fat steak (one meal per day) ☐ Salmon (one meal

PEDIATRIC MEDICAL ASSESSMENT · 12/03/2018  · ☐ ☐ Multiple Chemical Sensitivities ☐ ☐ Latex Allergy ☐ ☐ Other RESPIRATORY DISEASES ... Food Allergies, Sensitivities

PEDIATRIC MEDICAL ASSESSMENT · 12/03/2018  · ☐ ☐ Multiple Chemical Sensitivities ☐ ☐ Latex Allergy ☐ ☐ Other RESPIRATORY DISEASES ... Food Allergies, Sensitivities

APPOINTMENT DATE: REFERRING PROVIDER SIGNATURE: …...☐ BREAST ☐ CAROTID ☐ ECHOCARDIOGRAM ☐ GALLBLADDER ☐ OBSTETRIC ... ☐ BREAST FOR IMPLANTS w/o contrast ☐ CHEST Specify

APPOINTMENT DATE: REFERRING PROVIDER SIGNATURE: …...☐ BREAST ☐ CAROTID ☐ ECHOCARDIOGRAM ☐ GALLBLADDER ☐ OBSTETRIC ... ☐ BREAST FOR IMPLANTS w/o contrast ☐ CHEST Specify

 · 2020-01-14 · ☐ Ice Blue ☐ Jadestone ☐ Oyster Gray ☐ Platinum ☐ Sand Metallic ☐ Steel Blue ☐ Tectonic Silver ☐ Wasabi (BW logo, stripe) Black graphics Blue graphics

 · 2020-01-14 · ☐ Ice Blue ☐ Jadestone ☐ Oyster Gray ☐ Platinum ☐ Sand Metallic ☐ Steel Blue ☐ Tectonic Silver ☐ Wasabi (BW logo, stripe) Black graphics Blue graphics

LAMB CUT SHEET 2.0 - Trackside Butcher Shoppe · ☐ Whole ☐ Half ☐ Chops ☐ French style rib chop ☐ French style rib roast NECK ☐ Roast ☐ Sliced ☐ Ground SHANKS ☐

LAMB CUT SHEET 2.0 - Trackside Butcher Shoppe · ☐ Whole ☐ Half ☐ Chops ☐ French style rib chop ☐ French style rib roast NECK ☐ Roast ☐ Sliced ☐ Ground SHANKS ☐

Blog Post Ideas · Blog Post Ideas danischnakenberg.com0000000000©Simplify0Mommyhood ... ☐Twitter ☐Google+ Linked Up: ☐M ☐T ☐W ☐T ☐F ☐Sa/Su Post Title: Post Title:

Blog Post Ideas · Blog Post Ideas danischnakenberg.com0000000000©Simplify0Mommyhood ... ☐Twitter ☐Google+ Linked Up: ☐M ☐T ☐W ☐T ☐F ☐Sa/Su Post Title: Post Title:

Service Delivery Areas DFPS Texas and Regional Maps · ☐ Dallas ☐ Navarro*** ☐ Denton ☐ Palo Pinto*** ☐ Ellis*** ☐ Parker*** ☐ Erath*** ☐ Rockwall*** ☐ Fannin***

Service Delivery Areas DFPS Texas and Regional Maps · ☐ Dallas ☐ Navarro*** ☐ Denton ☐ Palo Pinto*** ☐ Ellis*** ☐ Parker*** ☐ Erath*** ☐ Rockwall*** ☐ Fannin***