BESS 2011 Registration Form

Welcome to BESS. To register your place, please complete the following information.

*All fields marked with an * must be filled in

Personal Details

First name:*

Last Name:*

Grade*

Grade Other

Hospital:

Hospital Other:

Address for Correspondence

Address 1:*
County:

Address 2:
Postcode:*

Address 3:
Country:

City:*

Contact Details

Email Address:*
Mobile phone number:

Daytime phone number:

Address for Invoicing:

Please fill in if this information is different to the one you have entered above.
If not please tick this box, to auto fill information from above

Hospital

Address 1
County

Address 2
Postcode

Address 3
Country

City

Booking Requirements

Early registration fees – for bookings made UP TO 16th January 2010 enjoy a discounted rate.
Early registration - £300
Late registration - £400

I am a: (please select)

Medical professional

Allied health professional

Surgeon

Therapist

Student

Member status: (please select)

Bess Member

Non Member

Please tick if you wish to attend one of the Master Classes on Thursday and/or Friday

Master Class A Master Class B Master Class C

Master Class A Master Class B Master Class C

I would like to attend and pay for: Conference package Price: Depends on date

Next of Kin
Please provide details in case of an emergency during the event

Name* Contact number*

Accommodation - Please tick all boxes applicable

Wednesday 24th March 2010 (£150) limited rooms available on a first come first served basis.

Thursday 25th March 2010 Accommodation for Thursday is included in the conference package

I will be making my own accommodation arrangements, please tick

Special requirements/requests (, disabled, gluten-free, vegetarian, etc)

Payment of Invoice

I confirm that I will make payment as follows:-

Cheque
Cheques to be made payable to BESS CONFERENCE and crossed a/c payee.
Please write the name of the delegate and workplace on the reverse of the cheque and send to:

Tracey Brock,
PA to Professor Andrew Carr
NDORMS
University of Oxford
Nuffield Orthopaedic Centre
Windmill Road
Headington
Oxford OX3 7LD
Tel: +44 1865 737421
Fax: +44 1865 737640
Tracey.Brock@ndorms.ox.ac.uk

PayPal
Pay on-line using your Debit or Credit Card, just follow the instructions on the on-line
Registration Form.

An administration fee of £3.50 per transaction will be charged.

Please read Booking Conditions prior to completing this form

Please tick to confirm you have read and agree with the Booking Conditions.
Click here to read the Booking Conditions

	Personal Details
	First name:*
	Last Name:*

	Grade*
	Grade Other

	Hospital:
	Hospital Other:

	Address for Correspondence
	Address 1:*		County:
	Address 2:		Postcode:*
	Address 3:		Country:
	City:*

	Contact Details

	Email Address:*		Mobile phone number:
	Daytime phone number:

	Address for Invoicing:
	Please fill in if this information is different to the one you have entered above. If not please tick this box, to auto fill information from above


	Hospital
	Address 1		County
	Address 2		Postcode
	Address 3		Country
	City

	Booking Requirements
	Early registration fees – for bookings made UP TO 16th January 2010 enjoy a discounted rate. Early registration - £300 Late registration - £400


I am a: (please select)	Medical professional Allied health professional Surgeon Therapist Student

Member status: (please select)	Bess Member Non Member

Please tick if you wish to attend one of the Master Classes on Thursday and/or Friday

Master Class A	Master Class B	Master Class C
Master Class A	Master Class B	Master Class C

I would like to attend and pay for:	Conference package	Price: Depends on date


	Next of Kin Please provide details in case of an emergency during the event
	Name*	Contact number*

	Accommodation - Please tick all boxes applicable
	Wednesday 24th March 2010 (£150)	limited rooms available on a first come first served basis.

	Thursday 25th March 2010	Accommodation for Thursday is included in the conference package

	I will be making my own accommodation arrangements, please tick

	Special requirements/requests (, disabled, gluten-free, vegetarian, etc)

	Payment of Invoice
	I confirm that I will make payment as follows:-
	Cheque	Cheques to be made payable to BESS CONFERENCE and crossed a/c payee. Please write the name of the delegate and workplace on the reverse of the cheque and send to: Tracey Brock, PA to Professor Andrew Carr NDORMS University of Oxford Nuffield Orthopaedic Centre Windmill Road Headington Oxford OX3 7LD Tel: +44 1865 737421 Fax: +44 1865 737640 Tracey.Brock@ndorms.ox.ac.uk

	PayPal	Pay on-line using your Debit or Credit Card, just follow the instructions on the on-line Registration Form. An administration fee of £3.50 per transaction will be charged.
	Please read Booking Conditions prior to completing this form
	Please tick to confirm you have read and agree with the Booking Conditions.	Click here to read the Booking Conditions