Airway Core Topics Workshops UCLH Application form

Airway Core Topics Workshops Day A one day course on ‘advanced’ airway techniques Wednesday 7th October 2009 Venue: 1st Floor West, Education Centre, 250 Euston Road, NW1 2PG (Opposite UCLH) Name Address Email Current Hospital Current Rotation Grade & Year     How many years / months anaesthetics have you done? Years What year did you qualify from medical school? Have you done any previous airway courses (and which one(s))? How did you find the course? Someone else / internet / poster / other …… Mobile phone Months Thanks for filling in this form. (Please email application and also print out to send with payment) Please send form and cheque (for £50) payable to “UCLH Charity Fund Ref.0779 (Airway Fund)” TO:- Dr Simon Clarke Anaesthetics Department, Podium 3, Maple Link corridor, University College Hospital, 235 Euston Road, London, NW1 2BU simon.clarke@uclh.org