Course Booking Form

This is a general booking form that covers most of our courses. If you are applying for the European Certificate in Holistic Dementia Care course, please use the course specific form that can be found on our website.

If completing this form by hand, please use BLOCK CAPITALS.

Personal details

Title: (Mrs / Miss / Mr / Dr) / First name:
Surname:
Address:
Postcode:
Phone number:
Email:
Would you like us to email you to inform you of future events that you may be interested in? / Yes / No
Where did you hear about this event? / Website / Prospectus / Other (please specify)
Position held:
Place of work:
Particular requirements:
(eg diet or access)

Course details

Course title:
Date: / Cost:


Payment details

Please note that confirmation of a place will not be possible without completed payment details.

Payment must be received 2 weeks before the start of the course.

I wish to book the above course and pay by (please tick and complete as appropriate):

Cheque

I enclose a cheque for £ _ payable to Northern Ireland Hospice.

Bank Transfer

Please transfer money to:

Account No: 50041653

Sort Code: 95-06-11

NB: If using the Bank Transfer option, please remember to write your name as the Reference

If after booking, you wish to withdraw from the course the following charges will be levied:

o  Withdrawal more than four weeks prior to the start of the course – full refund of fee less administrative charge of 10%;

o  Withdrawal less than four weeks prior to the start of the course – refund of fee less administration charge of 25% upon return of any course materials;

o  Withdrawal after the start of the course – no refund;

o  Request to defer received more than four weeks prior to start of course – 10% administration charge, plus any fee increase for the later course;

o  Request to defer received less than four weeks prior to the start of the course – administration fee of 20% plus any fee increase for the later course;

o  Request to defer received less than two weeks prior to the start of the course – administration fee of 25% plus any fee increase for the later course, plus return of course materials (in order to ensure candidate has latest editions of materials for course undertaken);

o  Request to defer after commencement of course – An administration fee of £25% plus any fee increase for the later course; and,

o  Under exceptional circumstances students will be permitted to defer from 2 sequential programmes, after which time they will have to re-enrol and incur full course fees.

If there are insufficient applicants to meet central costs the Northern Ireland Hospice reserves the right to postpone or cancel the course. Full discretion on any aspect of the Course rests with NI Hospice.

Please return your form to:

Education, Innovation & Research Department,

Northern Ireland Hospice,

Alexandra House,

74 Somerton Road,

Belfast BT15 3LH

Telephone: 028 90781836

Email:

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