Registered Charity Number: 1113276
Patients’ and Supporters’ Conference 2008
Saturday 28th June – Leicester Hilton Hotel
Delegate Registration
Delegate 1
Delegate 2
Delegate 3
Delegate 4
Title
First name
Surname
Age if under 18
Attending as
Please select...
Current Patient
Former Patient
Patient's Family
Professional
Medical Student
BCRT Supporter
Other
Please select...
Current Patient
Former Patient
Patient's Family
Professional
Medical Student
BCRT Supporter
Other
Please select...
Current Patient
Former Patient
Patient's Family
Professional
Medical Student
BCRT Supporter
Other
Please select...
Current Patient
Former Patient
Patient's Family
Professional
Medical Student
BCRT Supporter
Other
Wheelchair user?
Special dietary requirements
Address
Postcode
Telephone
Mobile
Email
PLEASE NOTE: NO CRECHE FACILITIES AND NO MORE THAN 4 DELEGATES PER FAMILY/ADDRESS. PLACES ARE LIMITED AND WILL BE ALLOCATED ON A 1ST COME 1ST SERVED BASIS.
