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Registration Form:

The Assisting Hand Assessment

Course Dates:1st-3rd September 2010
Venue:Institute of Child Health, London
Cost: £500.00

Please complete and return to: Lesley Katchburian/ Karen Edwards, Clinical Specialist PhysiotherapistsMovement Disorder Service, Floor 10, Nurses Home, GreatOrmondStreetHospital, Great Ormond Street, London, England. WC1N 3JH Tel: 020 7405 4200 ext 1140

Section 1

Your details:
Title: / First name: / Surname:
Home Address:
Postcode: Country:
Telephone contact details: / Email:
Profession:
Do you have any special requirements that we need to be aware of during your period of study? Yes/no
Please give details.
Section 2:
Your place of work:
Work Address:
Postcode: Country:
Section 3:
Your experience:
How long have you been working with children with cerebral palsy?
Approximately what percentage of the children, that you work with, present with hemiplegia?
Approximately what percentage of the children, that you work with, present with brachial plexus injuries?
Section 4
How did you hear about the course

Advert Internet Word of mouth Other:
Section 5
Booking and Availability
Please return your completed registration form with payment by cheque to secure your place.
Cheques payable to ‘GreatOrmondStreetHospital‘ please mark on the back of your cheque Special Trustees SN08
Alternatively an electronic bank transfer can be made please see attached sheet.
Section 6
Cancellations Policy
Refunds can be made if written notice is received by 8th August 2010. All refunds are subject to a cancellation fee of £50 for administration. We are unable to offer refunds on cancellations arising from events beyond our control, this includes participant illness, or inability to attend at short notice, adverse weather conditions, transport difficulties or terrorist alert.
Participants travelling from outside London: We advise you not to book travel until you have checked that the course you are booked on is not subject to changes of dates/cancellation. We are unable to reimburse expenses if courses are cancelled.
I have completes all sections of this form and have enclosed the tuition fee
Signed------
Name……………………………………………………. Date …………………………………..