international art therapy conference

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Finding Spaces, Making Places: Exploring social and
cultural space in contemporary Art Therapy practice.
Wednesday 13th – Saturday 16th April 2016
REGISTRATION FORM
*Full Name:
*Department &
Organisation:
Postal address:
*E-mail address:
Contact Telephone No:
Special Requirements:
(e.g. disabled access)
*Please note that the starred details will appear on our attendance list, to be distributed to delegates.
DELEGATE FEE
FEE (Early
Registration before
31 January 2016)
£400 (Full) or
£200 (one day)
FEE (after Early
Registration)
£500 (Full) or
£250 (one day)
£200 (Full) or
£100 (one day)
CONCESSION*
Students/Unwaged
AMOUNT PAYABLE
(please complete)
*Concession rate places are limited
All pages of this completed form and any remittance should be returned to:
Department of Social, Therapeutic & Community Studies, 21-23 St James, Goldsmiths,
University of London, SE14 6NW, UK
or by email to [email protected]
Print Name ……………………………………………………………
Signed …………………………………………………………………
Date …………………………………………………………………….
Delegate name:
PAYMENT METHODS
CHEQUES should be made payable to “GOLDSMITHS”
If you would like us to INVOICE your institution for the above amount, please complete
the information requested below.
Name of person attending conference.……………………………………………….
Invoice address.………………………………………………………………………….
…………………………………………………………………………………………
Your purchase order reference number ……………………………………………………
CREDIT/DEBIT CARD (those shown below are the ONLY cards we accept)
We are UNABLE to accept AMERICAN EXPRESS or DINERS CLUB
IMPORTANT
Please ensure
that your card is
valid for all
payments
CARD HOLDER’S DETAILS
Name of card holder
Type of credit/debit card: e.g. Visa, Mastercard
Full name as displayed on the card:
Card number (the long number in the centre of the card):
Card issue date (mm/yy):
Card expiry date (mm/yy):
Debit card issue number:
Security number (last 3 digits on back of card)
Payment will be withdrawn upon receipt. By signing this form you are giving permission for Goldsmiths, University of
London to deduct the above amount from your card to pay for attendance at the Art Therapy Conference 2016 If your
card is not issued in the UK, the transaction will be in your own currency and will be based on Reuters Wholesales
Interbank exchange rate plus 3% international conversion margin to replace the charge from your card company. If
your card is not issued in the UK and you choose to pay in GBP then please tick this box □. You will be subject to a
conversion fee or charge by your card company related to the value of the transaction. Please note: Refunds will only
be processed if asked 4 weeks prior to the Conference.
Signature of card holder: _________________________
Date: __________________
N.B. The person signing this form must be the card holder. If you are sending this form via e-mail then please send an
accompanying email to [email protected] stating that Goldsmith’s, University of London is
authorized to deduct the above amount.
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