BOOKING FORM AND PAYMENT DUE BY 31st OCTOBER 2018 THANK YOU R E G I S T R A T I O N F O R M: I wish to register for the 20th MASCIP Conference “Below the Belt – Bladder, Bowel & Sexual Issues” 22nd November 2018 @ Burleigh Court, Loughborough Name: Organisation/Place of work: Job Title: Address: Postcode: Telephone contact: Email: C O S T S: I am a full member of MASCIP: YES [ ] £110 NO [ ] £150 I wish to pay by: 1. Cheque [ ] 2. Internet [ ] 3. Invoice (SCI Centres only) [ ] 1. Please make all cheques payable to: MASCIP and send to Lorraine Hedgecock (address below) 2. Internet banking details will be sent to you upon receipt of this booking form. 3. Or please send me an invoice to (SCI Centres only): Contact Name: Postcode: Email: O T H E R I N F O R M A T I O N: Dietary Requirements: If you have any special dietary requirements, please state: Wheelchair Users: Please state: [ ] If yes, are you bringing a PA: [ ] If bringing a PA then £10 charge to cover refreshments is required: [ ] Please return your completed registration form to: Lorraine Hedgecock, MASCIP Secretary, c/o Dot Tussler – Physio Lead, National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, Bucks HP21 8AL Or email to: mascipsecretary@gmail.com We hold the information you supply us on our database and will use this to communicate with you in relation to conferences , study days  and other requests made by you. From time to time MASCIP may send you details concerning other spinal injury conferences, events or related information.  By completing your email or telephone details and submitting this form, you will be indicating your consent to receiving marketing information from MASCIP , if you do not wish to receive information please tick here [   ]    Please note the delegate fee is non-refundable. BOOKING FORM AND PAYMENT DUE BY 31st OCTOBER 2018 THANK YOU www.mascip.co.uk