Registration Form
Monday 11 – Tuesday 12 June 2012
Queen’s University Belfast
Please complete and email to ukccrf@icnarc.org by Wednesday 6 June 2012
or, if sending with payment, post to: ICNARC, Tavistock House, Tavistock Square, London WC1H 9HR
Delegate Details
Title:
Name:
Job title:
Organisation:
Address:
Postcode:
Email:
Special dietary requirements:
Telephone:
Booking
Consultants/Trainees
Forum and Delegates’ Dinner
Forum
Nurses/AHPs
£115
Forum and Delegates’ Dinner
£75
£80
Forum
£40
All prices are inclusive of VAT, where applicable.
One day rates are available on request – please contact ukccrf@icnarc.org
Parallel Session
Please select which Parallel Session you wish to attend:
1. Rehabilitation in critical care
2. Translational research in critical care
Payment
Please tick one of the following
I enclose a cheque (payable to ICNARC) for the Forum and Delegates’ Dinner
I enclose a cheque (payable to ICNARC) for the Forum
Please send an invoice to me at the address above
Please send an invoice to:
Title:
Name:
Job title:
Organisation name:
Address:
Postcode:
PO number (if required):
Please check with your Finance Department if you are unsure where your invoice should be sent to.
Please note payment is due in advance of the Forum
Cancellation policy
A full refund for cancelled places will only be given if ICNARC are informed in writing at least 7 days prior to
the event. No refund will be given to places cancelled less than 7 days prior to the event or to no shows.
ICNARC, Tavistock House, Tavistock Square, London WC1H 9HR  T: +44 (0)20 7388 2856  F: +44 (0)20 7388 3759  E: ukccrf@icnarc.org  W: www.icnarc.org
Registered as a Company limited by Guarantee  Registered No. 2946727 (England)  Registered Charity No. 1039417