Course Booking Form
Name:
Grade & specialty:
Name of Course:
Date of Course:
Venue of Course:
Course Fee:
Home address:
Telephone:
Email:
Hospital currently working:
Please send payment in the form of a cheque made payable to Barts Health NHS Trust to
secure your place. Once your application and payment have been received your place will be
secured and you will be sent a confirmation email. Non attendance once confirmed is non
refundable. All cancellations must be made no later than 4 weeks prior to your course date. If
a cancellation is made within the 4 weeks of your course date a repayment of the full course
fee will have to be paid. Please ensure you have allocated the correct amount of study/annual
leave to avoid non attendance on the day. Please return your completed booking form to:
Newham University Hospital:Simulationadmin@newhamhealth.nhs.uk
Whipps Cross University :Dawn.zucker@bartshealth.nhs.uk or Shuhana.sharmin@bartshealth.nhs.uk
The Royal London:Sajeda.khan@bartshealth.nhs.uk or Iffatara.begum@barthealth.nhs.uk