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					              THE INTENSIVE CARE SOCIETY
              Seminars at Churchill House
              VENTILATION UPDATE

Thursday 4th June 2009
REGISTRATION FORM

Please complete a separate Registration Form for each delegate wishing to attend (photocopy this form as required).
Return completed form to:

The Intensive Care Society, Churchill House, 35 Red Lion Square, London, WC1R 4SG
Tel: 020 7280 4350
Fax: 020 7280 4369
IF YOU ARE FAXING THIS FORM, PLEASE ADD YOUR SURNAME AT THE BOTTOM OF EACH PAGE.
Email: robina@ics.ac.uk
We regret applications cannot be accepted unless accompanied by payment.
Please note, contact details given on this form, will be used for all future ICS correspondence until the office is otherwise notified.

Prof/Dr/Mr/Mrs/Ms ______________________________

Forename_____________________________________________________________________________________________

Surname______________________________________________________________________________________________

Preferred Badge Name _________________________________________________________________________________

Job Title______________________________________________________________________________________________

Hospital/Place of Work __________________________________________________________________________________

Address______________________________________________________________________________________________

_____________________________________________________________________________________________________


Postcode __________________                                  Fax no. _________________________________________

Email _______________________________________________ Telephone no. ____________________________________

Please give details of any special dietary requirements you may have:

   No Preference          Vegetarian        Vegan            No Pork      No Beef

   Other please specify                                  .

Please give details of any special access arrangements you may require due to disability (Data Protection: By completing this
section you are giving the Society explicit consent to use / pass on this information to individuals / organisations relating to health
and safety and your wellbeing during the Meeting and associated events).

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

How did you hear about this meeting? (Please tick the appropriate box)

   ICS mailshot             Colleagues          Poster            ICS Newsletter        ICS Website

   Non-ICS Website             Other please specify



FOR SOCIETY USE ONLY

Date entered ___________________                                              Confirmation/Receipt ____________________


Payment details _________________                                            Membership No ________________________




                                                                    -1-    SURNAME _______________________________
             THE INTENSIVE CARE SOCIETY
             Seminars at Churchill House
             VENTILATION UPDATE

Thursday 4th June 2009
REGISTRATION FORM
CLOSING DATE & CANCELLATION POLICY
                                                                   th
The closing date for paper registrations is 5.00pm Thursday 28 May 2009. Delegates wishing to register after the closing date
                                                      nd
should telephone the Office by 5.00pm Tuesday 2 June 2009 to check availability or they may be turned away on the day. If
there are available spaces, late registrants will be subject to a £10.00 surcharge to cover additional administration costs.

Amendments to registrations will also be liable to a £5.00 administration charge. Until three weeks prior to the meeting, cancelled
registrations will be refunded subject to an administration charge of £5.00. Thereafter the following charges will be made:

                                                  th
3 weeks - 50% (Week commencing Monday 18 May 2009)
                                        th
2 weeks - 75% (Week commencing Monday 25 May 2009)
                                        st
1 week - 100% (Week commencing Monday 1 June 2009)


FOR SOCIETY USE ONLY

Date entered ___________________                                          Confirmation/Receipt ____________________


Payment details _________________                                         Membership No ________________________




                                                                -2-    SURNAME _______________________________
            THE INTENSIVE CARE SOCIETY
            Seminars at Churchill House
            VENTILATION UPDATE

Thursday 4th June 2009
REGISTRATION FORM

Please tick your membership status

I am a paid up ICS Member.

I have already submitted a Membership application form to join the ICS and am eligible for the
discounted rates. My election is still pending.

I would like to apply for ICS Membership before the Meeting and therefore be entitled to the
discounted rates for this Meeting.

In order to ensure your registration is processed at the discounted rate, please complete and ensure that the
membership form is signed by yourself and two members of the Society where indicated. Please send this along
                                                                                   th
with your registration form. It must be received no later than 5.00pm Thursday 28 May 2009 or you will be
required to pay the full non-member delegate fee where necessary.

No, I do not wish to apply for Membership, but do wish to attend the Meeting




Please tick your attendance requirements and return BOTH forms to the ICS office

            th
Thursday 4 June 2009


ICS MEMBERS REGISTRATION FEES                                       NON-MEMBERS REGISTRATION FEES


 Consultant-Standard Booking                                 Consultant-Standard Booking
                         th                                                          th
 Until 5.00pm Thursday 28 May 2009                           Until 5.00pm Thursday 28 May 2009

 £140                                                        £230


 SAS/Trainee/Nurse/AHP s-Standard Booking                    SAS/Trainee/Nurse/AHP s -Standard Booking
                         th                                                          th
 Until 5.00pm Thursday 28 May 2009                           Until 5.00pm Thursday 28 May 2009

 £110                                                        £195




                                                             -3-    SURNAME _______________________________
              THE INTENSIVE CARE SOCIETY
              Seminars at Churchill House
              VENTILTATION UPDATE

Thursday 4th June 2009
REGISTRATION FORM


                                                     PAYMENT DETAILS
I have enclosed / completed:

My credit card details:

Please debit my credit card with the total amount owing to attend the ICS Seminars at Churchill House as booked above;
or

I enclose a cheque for £_______
Cheques should be made payable to the Intensive Care Society . Please send payment with completed registration form to:
The Intensive Care Society, Churchill House, 35 Red Lion Square, London, WC1R 4SG

Credit Card Details:           (Please note, we do not accept AMEX)

Card Type (master, visa etc) ______________________________________________________________

Card Number ___________________________________________________________________________

Card Expiry Date ____________________________

Card Issue Date _____________________________

Issue Number (for switch or solo cards only) __________________________________

CV2 Number (3 digit number on signature strip) _______________________

Name on Card (exactly as appears on the card):

___________________________________________________________________

ICS Membership Number (if known / relevant) :_____________________________

Name of Member / Delegate: ___________________________________________

Address details of cardholder (as on credit card statement):

                                                                      ..

                                                                      ..

Contact name if different to member / delegate name                                 .

Contact tel number (in case of enquiry)

Cardholders signature                                                      ...

Please debit my account the sum of:


This form MUST NOT be emailed         Please ONLY Post or fax due to security reasons to:

The Intensive Care Society, Churchill House, 35 Red Lion Square, London WC1R 4SG
Fax: +44 (0)20 7280 4369     In case of enquiry Tel: +44 (0)20 7280 4350




                                                               -4-   SURNAME _______________________________