23rd Annual Conference

Registration

(BOOKINGS WILL BE TAKEN ON A FIRST COME, FIRST SERVED BASIS)

Membership No. if applicable:

1. Contact Details:

(Please complete clearly and in BLOCK CAPITALS -
using a separate form for each person registering - photocopies are accepted)

Title:

Mr Miss Mrs Ms Dr Prof Other (please state)

Gender:

Male Female

First Name:

Surname:

Position:

Department:

Organisation:

Building:

Street:

City:

County:

Country:

Post/zip code:

Email:

Tel No:

Fax:

2. Registration Fee:

including drinks reception on Wednesday evening and lunch on Thursday and Friday -
non refundable

(Please select what's applicable)

Full attendance only

HEART UK MEMBER (Junior) -
Health Professional Nurses, Dietitians, Ancillary Health Professionals

Junior member at £130

HEART UK MEMBER (Senior) -
All other health professionals including doctors and consultants

Senior member at £180

HEART UK NON MEMBER (Junior) -
Health Professional Nurses, Dietitians, Ancillary Health Professionals

Junior non member at £160

HEART UK NON MEMBER (Senior) -
All other health professionals including doctors and consultants

Senior non member at £210

STUDENTS - registrations will not be processed unless accompanied
by a letter from your head of department confirming your status

Students at £80

PATIENTS

Patients at £0

(select as appropriate)

HEART UK MEMBER - DAY RATE

THURSDAY

FRIDAY

Junior member at £90

Senior member at £110

HEART UK NON MEMBER - DAY RATE

THURSDAY

FRIDAY

Junior non member at £110

Senior non member at £130

3. Accommodation:

hotel option fully booked

University

Wed 24 June

Thurs 25 June

Fri 26 June

Bed and Breakfast, single en-suite room -
GBP £50 per night

Crowne Plaza John Lennon Airport Hotel (4*)

Bed and Breakfast - double room for single occupancy -
GBP £120 per night

Bed and Breakfast - double room for double occupancy -
GBP £120 per night

Smoking*

Non smoking*

*(applies to hotel accommodation only)

4. Drinks Reception:

(Wednesday 24 June)

IMPORTANT - PLEASE INDICATE IF YOU ARE ABLE TO ATTEND (1 x complimentary place per registered delegate)

Yes

No

I wish to purchase (indicate number of tickets here) additional tickets at GBP £20 each

5. Conference Dinner:

(Thursday 25 June)

HEART UK Members, Non Members and Patients:

£40

Students:

£30

6. Surcharge:

Applicable after Friday 5 June (non negotiable)
£40 Per booking:

(Please enter the total of sections 2-6)

Total: £

Please specify any special dietary requirements

Vegetarian Lactose Intolerant No Fish No Meat Vegan Other:

Do you have a disability?

Methods of Payment:

1. By credit card:

Please call me to debit my MasterCard/Visa/Switch for the total amount. Please remember to include your
security word here which HEART UK will quote when they call to take your card details.
Security word:

2. By cheque:

Please make all cheques payable to "HEART UK Trading Co Ltd"

3. By invoice:

(Invoices may only be requested until Friday 1 May 2009 otherwise payment must be made by cheque
or credit card.) (NOTE: Invoices requested will be subject to a £10 administration fee (per invoice) which
will be added to your total booking fee). Invoices will be dispatched via HEART UK's office in Maidenhead.

Name of organisation:

Contact name for invoice:

Invoice address:

Postcode:

Purchase Order No:

CPD:

(tick as appropriate)

Will you require:

a CPD certificate (for those registered with the Royal Colleges only)?
a general certificate of attendance?
an RCN certificate?

Where did you hear about this conference:

(tick as appropriate)

By post
Word of mouth
By email
Other meeting (Indicate which meeting):
HEART UK Digest
Flier
HEART UK website
Advert or diary listing in journal (Indicate which publication or journal):
Work
PCCS
Invited speaker
Sponsor (Indicate sponsor company name):
Other:
Other society/association (please list):

Personal Data supplied to us is subject to the Data Protection Act 1998. This data may be used to supply you with information relevant to your business. HEART UK will supply you with information relevant to the Annual Conference.

Tick here if you DO NOT wish to receive any information on other meetings and events organised by HEART UK
Tick here if you DO NOT wish to receive information from other organisations on meetings and events which are approved by HEART UK
Tick here if you DO NOT wish to receive information from other organisations on products and services approved by HEART UK