MEMBERSHIP APPLICATION FORM
Intuition, Authority and Leadership in Turbulent Times
A Tavistock Group Relations Conference
18th-22nd December 2017, Tavistock Centre, 120 Belsize Lane, London NW3 5BA
NB CLOSING DATE for APPLICATIONS: 12noon 10th NOVEMBER 2017
Application Details:
Surname: (Please print) …………………………………………………………………………………
Forename: (Please print) ……………………………………………………………………………….
Title: Dr/Mr/Mrs/Miss/Ms:...... Age:......
Gender:…………………………………………………………………………………………………………….
Home Address:......
......
Post Code:...... …….
Email:………………………………………………….
Reliable Telephone:......
Name of main employing institution:
Present Job Title:
Discipline:
Main responsibilities:
If you are a student or trainee at the Trust, please give:
Course Code ……………
Course Name ……………………………………………………….
Please discuss any special needs with the Conference Pre Administrator.
Please note Course leads and Conference Directors reserve the right to withdraw membership, or not agree to membership of a given conference, if there is evidence that attendance might adversely affect the prospective conference member and / or the experience of other members within the conference, if they were to attend.
Declaration:
I commit myself to attending the whole programme from
Monday 18th-22nd December 2017
Signed: Date:
r (Please mark with X if sent by email)
Arrangement for Payment (please tick)The conference fee is: £ 650 (Student fee) £750 (Non-student fee/External)
Who will be responsible for your fees? Yourself Your Sponsor
If you are a Tavistock student, please indicate if the fee is covered by your course
Sponsor name:
Invoice Address:
Cancellation Charges:
- Less than 2 weeks in advance of first day: 100%
- Between 2-8 weeks in advance of first day: 50%
- Between 8-12 weeks in advance of first day: 25%
Please return the completed application form by email to the pre-conference administrator, Kara Florish, at
CLOSING DATE for APPLICATIONS: 12 noon 10th NOVEMBER 2017
Please keep a copy of the completed form for your reference
EQUAL OPPORTUNITIES MONITORING INFORMATIONFull Name:
Please use block capitals and underline your family name
Your help in completing the following questions will enable us to monitor the effectiveness of our recruitment and admissions policies. The data will be stored in confidence by the Directorate of Training and Postgraduate Education, and will be used by the Higher Education Statistical Agency (HESA) and The Tavistock and Portman NHS Trust for statistical purposes.
If you object to providing this information please indicate this in the box provided.
Please state your nationality or, if a holder of dual nationality, please indicate your country of birth:Please state which country you regard as your permanent home:
Ethnic Origin (please tick one only):
White – British (11) / Asian or Asian British - Indian (31)White - Irish (12) / Asian or Asian British - Pakistani (32)
White - Scottish (13) / Asian or Asian British - Bangladeshi (33)
Irish Traveller (14) / Chinese (34)
Other White Background (19) / Other Asian Background (39)
Mixed - White and Black Caribbean (41) / Black or Black British - Caribbean (21)
Mixed - White and Black African (42) / Black or Black British - African (22)
Mixed - White and Asian (43) / Other Black Background (29)
Other Mixed Background (49) / Other Ethnic Background (80)
Not Known (90) / Information Refused (98)
If you ticked number (19), (29), (39), (49) or (80), please describe your ethnic origin using your own words:
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