Gloucestershire Hospitals NHS Foundation Trust
CHELTENHAM INSTRUCTIONAL KNEE ARTHROSCOPY COURSE
FRIDAY 17th May 2018
Cheltenham Racecourse
REGISTRATION FORM
Name:
Address for correspondence:
Email:
Contact telephone number:
BaseHospital:
Grade (please state):
Places on the course are strictly limited in number, priority will be given to Orthopaedic Registrars, Clinical Fellows and Associate Specialists.
I wish to apply for registration on this course. I understand that the fee is non-returnable once registration has been confirmed by Cheltenham Postgraduate Medical Centre. Cheques for application which are not accepted will be returned.
Please specify any special dietary requirements ………………………………………………….
Signed: Date:
Please return this form to:
Lindsey Buckenham
Department of Medical Education
Sandford Education Centre
Keynsham Road
Cheltenham, Glos GL53 7PX
Payment of £150.00 via cheque (please attach to form and made payable to “Gloucestershire Hospitals NHS Foundation Trust”)
Or via credit / debit card (details on how to pay will be supplied once the form has been received)