Register: 4 - 7 March 2019

Your Details:

Title

First name

Surname

Date of birth

Male

Female

Other

Occupation

Home address

Postcode

Contact telephone no.

Email address

Do you have a disability?

If yes, please detail

If you have any dietary requirements please detail here.

Emergency Contact Details:

Emergency contact name

Relationship to you

Emergency contact number

Payment:

I would like to pay over the phone (please see below for telephone payment details)

Please raise an invoice to myself or my organisation (please enter details below)

Details for telephone payments: For telephone payments, please call Janice Denham in normal office hours on Tel: 02476 575758, with the following details to hand:
Full name: Course name: Intensive introduction to ethical decision-making in healthcare Course payment reference: S.MRMB.0006.EXP Amount: £400 Name on card: Expiry date: Security code:

Details for invoicing: If you have selected to pay by invoice, please provide the details requested below. Invoices will be raised and sent directly to customers based on this information.

Company name

Invoice address (a postcode must be provided)

Finance email

Finance telephone no.

For the attention of: (person and/or department)

Purchase order number: (if it needs to be quoted on the invoice)

Data Protection Statement

I understand that:

The University of Warwick will use your personal data, including without limitation, name, address(es), email address, contact numbers, age, gender, date of birth, department, year of study, student status, type of course, department and details of my progress on my course (Personal Information) for the purpose(s) outlined in this notice and the Universitys Data Protection Guidelines: http://www2.warwick.ac.uk/services/vco/exec/registrar/legalservices/dataprotection Your personal data will not be shared or disclosed to any third parties external to the University of Warwick. By submitting this questionnaire you agree to your personal data being processed and used by the University of Warwick for the purposes outlined above and that the data will be held in perpetuity to maintain the integrity of The Universitys Student and Academic Records. For further information regarding: how your information is held, including how we maintain the security of your information, your rights to access information we hold about you, how to update us on any changes to your details or to withdraw your consent for your data to be used for the purposes outlines above then please contact: pgt-portfolio1@warwick.ac.uk For further information, please see: http://www2.warwick.ac.uk/services/vco/exec/registrar/legalservices/dataprotection

Cancellation Policy

Cancellation policy: A delegate may withdraw from a CPD event 31 days or more before the start of the event without charge. If a delegate withdraws from a CPD event 30 days or less before the start of the event then they will be liable for 50% of the fee.

Declaration

I Agree

By ticking the box above I confirm that: I have read and understood the Data Protection Statement and agree for the University to use my personal details I confirm that, to the best of my knowledge, the information given in this form is correct and complete. I confirm that I am aware of the scale of the fees and charges on the due dates of payment as per the cancellation policy. I understand that should my sponsor at any time fail to pay my fees and charges that are due, I will be personally liable for them. Note: A registration is not valid unless fees are paid or full details of sponsors are provided.

Where did you hear about the course?:

Mail out

Warwick Medical School website

Other website

Newsletter

Word of mouth

Other

If other, please specify

Privacy notice

The data you provide is used solely to help us improve the delivery of our courses.

The University of Warwick is the Data Controller of any information you have entered on this form and is committed to protecting the rights of individuals in line with Data Protection Legislation. The University's Data Protection webpages provide further information on your rights and how the University processes personal data. If you wish to submit a data subjects rights request, make a complaint or report a suspected personal data breach, please contact the University’s Data Protection Officer by email at infocompliance@warwick.ac.uk.

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