Conference booking form - ATAXIA UK 40th ANNIVERSARY CONFERENCE

Document Sample
Conference booking form - ATAXIA UK 40th ANNIVERSARY CONFERENCE Powered By Docstoc
					                                  Ataxia UK Annual Conference
                               9 October 2010, Radisson Blu Hotel
                                 Waltham Close, Stansted Airport
                                        Essex CM24 1PP
                                        Tel: 01279 661012                                Everybody In!

                           Conference Booking Form
                  The theme of the 2010 Annual Conference will be Everybody In!
 Please complete this form and return it to the Ataxia UK office as soon as you can to reserve
        your place(s) at the conference. You can also book online at
Prices (all per person; one child under 12 can go free if sharing with parents, dependent on
availability. A supplement of £30 per room will be charged if more than one child is attending as
adjoining rooms will be required)
Conference only (includes lunch):             £20
Dinner on Saturday night                      £31
Saturday accommodation                        £60
Friday night accommodation                    £66    (includes light buffet)
            Please complete the information below for each person attending the conference, up to four people.
                          Please indicate if you have any extra needs or are a wheelchair user.

Person 1
Name:                                                                 DOB:
Has ataxia?           Any special requirements:

Person 2
Name:                                                                 DOB:
Has ataxia?           Any special requirements:

Person 3
Name:                                                                 DOB:
Has ataxia?           Any special requirements:

Person 4
Name:                                                                 DOB:
Has ataxia?           Any special requirements:
Number of people for conference only @ £20 each:
Number of people for Saturday dinner @ £31 each:
Number of people for Saturday night @ £60 each:
Number of people for Friday night@ £66 each:
Number of double rooms:                   Twin rooms:                 Single rooms:
Additional bed per room required Y/N                   Adjoining room required Y/N

                                                              Total amount due:          £

I enclose a cheque/postal order made payable to Ataxia UK for the total sum of: £ _________
Please debit my Visa/Mastercard/Switch/Maestro/Solo card for: £ _________
       Name on card: ______________________________________________________
       Card Number:
       Expiry Date:
       Start Date:                                          Issue Number

       Card security code (this is the last three digits on the back of the card):

       Signature of card holder: ___________________________ Date: ______________

      Your details (booking confirmation and further information will be sent to this address)

  Title:             ________________________________            Address:         ________________________________

  Forename:          ___________________________                                  ___________________________

  Surname:           ___________________________                                  ___________________________

  Telephone:         ___________________________                 Postcode         ___________________________

  Email:             ___________________________

Have you attended an Ataxia UK Conference before? Yes                               No

During our conferences film recordings and photographs are taken. Do you and your party give
permission to be featured on these?
                                              Yes                       No

In 2010 we plan to include what type of ataxia people have or if they are a carer/parent on badges
to help people mingle more easily (eg type of ataxia). If you are happy to be included in this,
please indicate below what your badge should say:
 Please note: St. John’s Ambulance staff will be available during the conference, but
      delegates must arrange to be accompanied with a carer if one is needed.

  To be certain of a place please complete and return this form with your full payment now
By post: Please return your completed booking form along with your payment/credit card details
to Mike Garrett at Ataxia UK, Lincoln House, Kennington Park, 1-3 Brixton Road, London SW9
By telephone or fax: Please telephone Ataxia UK on 020 7582 1444 to book, or fax your completed
booking form to 020 7582 9444. Email
                             Thank you. We look forward to seeing you there!

Ataxia UK works across the whole of the UK and is a charity registered in Scotland (no SC040607) and in England and
Wales (no 1102391) and a company limited by guarantee (4974832).