Application/registration form
 Student/trainee member
UNCERTAINTY AND
 Staff member
CONVICTION IN GROUPS
AND ORGANISATIONS
 Training group member (please tick)
A five-day non-residential
TITLE
group relations conference at the
______________________________________
Tavistock Centre, 120 Belsize
FORENAMES
Please complete in full in BLOCK letters
______________________________________
Lane, London NW3 5BA
______________________________________
Conference fees
______________________________________
SURNAME(S)
Students/Trainees
If included in course fees
Otherwise
No charge
£450
Trust staff
If sponsored by Trust
Otherwise
No charge
£450
Training group
£800
______________________________________
GENDER
DATE OF BIRTH
______________________________________
HOME ADDRESS
The closing date for applications is
12 noon Monday 9 November 2015.
Early booking is recommended.
__________________________________
To book a place please fill in this
application/registration form and
return by post as hard copy, or email
it to the Pre-conference Administrator
Naiara Labaca
Tavistock Consulting
______________________________________
POSTCODE
______________________________________
TELEPHONE
94 Belsize Lane, London NW3 5BE
work
+44 (0)20 8938 2584
home
NLabaca@TavistockConsulting.co.uk
mobile
______________________________________
E-MAIL
EMERGENCY CONTACT (next of kin)
PAYMENT ARRANGEMENTS

The fee will be fully/partly covered by the
COURSE NAME
Please tick one
following funds/sponsor (please give full
details including invoice address and
______________________________________
COURSE YEAR
______________________________________
 The conference fee is covered by my
EMPLOYING INSTITUTION
TRAINING
your Course Director)
Please give details of any training undertaken
(including any group relations experience) that
contact details).
course arrangements. (Please check with

may be relevant to the conference, giving name
The conference fee is not covered by my
course arrangements and I enclose
of institution and dates.
payment for £450.

Please invoice me for the fee of £450.
Invoice Address:
______________________________________
CURRENT WORK TITLE
______________________________________
 I am employed by the Trust and
sponsored by my Department.
______________________________________

Please give details.
DISCIPLINE
______________________________________
______________________________________
MAIN ROLE(S)
WHAT DO YOU HOPE TO GAIN FROM
______________________________________
 I enclose payment of the Training group
member fee of £800.
ATTENDING THE CONFERENCE?

Please invoice me for the Training group
member fee of £800. Invoice Address:
______________________________________
WHERE DID YOU LEARN ABOUT
THIS CONFERENCE?
______________________________________
If you are a student/trainee at the Trust indicate

COURSE CODE
The Tavistock and Portman NHS Foundation Trust
follows an equal opportunities policy in all its
practice and teaching. All applicants will be
considered on the basis of suitability for this
conference irrespective of disability, gender, age,
ethnic origin, sexual orientation, religion, or social
class. The information you provide will be treated
as confidential.
Please discuss any special needs with the Preconference Administrator.
______________________________________
DECLARATION
I commit myself to attending the whole
conference programme from
Monday 14 – Friday 18 December 2015.
______________________________________
SIGNATURE
______________________________________
DATE
______________________________________
Please return the completed form to the
Pre-conference Administrator to the address
shown in the previous page, keeping a copy for
your reference.
Cheques should be made payable to the
‘Tavistock and Portman NHS Trust’.
Cancellation Charges
Between 8–12 weeks notice
25%
Between 2–8 weeks notice
50%
Less than 2 weeks notice
100%
v 150525