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 www.ataxia.org.uk 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: Totals: 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: £ Payment I enclose a cheque/postal order made payable to Ataxia UK for the total sum of: £ _________ Or: 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 6DE. 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 email@example.com 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).