Course title: Syringe Pump & Symptom Management in EoL Care Course Date: 18th September 2018 Fee: £75 per person Attendee details: Name Job Title Email Address Telephone Professional group/area of practice: Organisation: Address: Booking Conditions: The closing date for the application is 7 days prior to the start date. No refunds can be made after the closing date or where participants do not attend without prior notice to Education Adminstration. Your place on the course will be confirmed following receipt of your booking form and fee. In the event of a booking being cancelled less than two weeks before the course start date, 50% of the course fee will be charged. This form can be photocopied for additional applications. Those named above will be contacted with information about their course and other courses that may be of interest. All data received is processed in accordance with the Data Protection Act. Please view our privacy policy on our website for information about how we use your data, including how to opt out of further communication. Payment Details: Please select your method of payment: By Cheque. Please make the cheque payable to Saint Francis Hospice & place the course name on the back of the cheque By BACS. Please email Education Centre, education@sfh.org.uk By Credit Card. Please call 01708 758646 By Invoice. Please invoice the following if different from the above address. Name: Address: Email: Signature: Date: Data Protection Act: We’d like to send you information about Saint Francis Hospice and the work your continued support enables us to do. Please tick here if you DO NOT want to recieve communication by: post. Please tick here if you WANT to receive comunications by: email phone SMS text. We never sell, share or swap personal details and it’s easy to change your preferences or stop communications at any time by calling 01708 723593. Our data security and privacy statement is available on request or by visiting our website www.sfh.org.uk. Please note: Your place on this course is not guaranteed until you have received confirmation from us in writing. Please return form to: Post: Saint Francis Hospice, The Pepperell Education Centre, The Hall, Havering-atte-Bower, Romford, Essex, RM4 1QH. Email: education@sfh.org.uk Call: 01708 758646