Epidemiology for Clinicians by I66V751d


									                                Epidemiology for Clinicians
                                    4th-6th January 2012

                                        Application Form
Title:                    Forename:                               Surname:

Clinical Specialty – or other Discipline:


Phone:                                            Mobile Phone:

Email:                                            Will you require parking?

How did you hear about the course?

Catering Requirements:

Please indicate your catering requirements by ticking the appropriate boxes.

  Wednesday,                       Thursday,                     Friday,
    th                             th                          th
   4 January                      5 January                   6 January
Lunch                          Lunch                        Lunch
Drinks Reception               Drinks Reception
Dinner                         Dinner

Do you have any special requirements?


                                                        Cost £                Paid £
Full Residential                                         300
Non-Residential                                          150

Payment in full should be made by cheque payable to: Medical Research Council
Refunds for cancellations will be payable up to 25 November 2011 (minus £50 administration fee),
thereafter no refunds are possible.

The application form plus full payment should be sent to:

                   Mrs Julie Hands
                   MRC Epidemiology Unit
                   Institute of Metabolic Science
                   Box 285, Addenbrooke’s Hospital
                   Hills Road, Cambridge
                   CB2 0QQ
                   Deadline: 30 September 2011

Data Protection Notice: The organisers will not pass your contact details to others without your
consent. Please note that your information will be used for the purpose of organising this event and
your name and clinical speciality or discipline will be added to the list of participants which will be
distributed at the event.

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