DMI Managing Challenging and Aggressive Behaviour
2014 Course Booking form
Price: Care Match discounted rate (inc. free lunch) you will be charged at £96 per delegate (no VAT).
4th June - Stoke-on-Trent (YMCA North Staffordshire, ST1 3AE)
Details: This full day course runs from 9.30am to 4.30pm, the course will begin promptly so please arrive 15 minutes
before the start time. The scheduled finish time may change subject to the learning needs of the group. Fees include
training pack, certificate of attendance, refreshments, lunch and free parking. Completed booking form must be
returned via email/post before the above closing date. Places are limited and will be offered on a first come first
served basis. Please do not wait for the closing date as generally courses are booked much earlier.
Delegate/s Details
Delegate Name 1:
Job Title:
Delegate Name 2:
Job Title:
Delegate Name 3:
Job Title:
Delegate Name 4:
Job Title:
Delegate Name 5:
Job Title:
Delegate Name 6:
Job Title:
Name and address of the Organisation:
Tel No:
Booking contact name:
E-mail :
Purchase order no/ref:
Cheques payable to:
South Staffordshire and Shropshire Healthcare NHS FT
(please write your organisation’s name on the back of the cheque)
Note: Terms and conditions apply as stated in this booking form. By completing this form you agree to the terms and
conditions as detailed in this form.
Please tick or type “Y”
 I am forwarding a cheque for the course fee as above

Please send me an invoice
Any specific requirements i.e. access etc.
Please sign opposite/add your name to confirm that you have read, understood &
agree to the terms & conditions of this booking form. (If you are emailing this form
and don’t have an electronic version of your signature the email will act as the
confirmation that you have agreed to the terms & conditions)
Signature:______________________
Please return this form to us by before the closing date of the appropriate event via
email to: michelle.evans@sssft.nhs.uk or fax: 01785 221292 or post to: Michelle Evans,
South Staffordshire and Shropshire Healthcare NHS FT, HRODE Directorate, Trust HQ, St.
George’s Hospital, Corporation Street, Stafford, ST16 3SR
Terms, Conditions and Agreement
Refunds & Cancell ati ons: W e are unable t o mak e refunds or acc ept cancellations for any reason less than 10 days in
advance of the start date of the training/workshop regardless of when the booking was made/confirmed. Cancellations made 10 days or
less from the start date of the training workshop or non-attendance or no show for any reason will incur the full cost of the training.
Payments: Your place will be confirmed at the course once we send the “Confirmation of Place” correspondence via email or post and
therefore you will be liable for the payment as detailed in this form. All payments must be made fully in advance before/by the training
event date. Please note that the “Booking Contact” as stated above is responsible for booking the delegate/s to the training course
remain/s personally responsible for making all the payments in case where your organisation/department does not pay therefore you
must ensure that you secure your funding before submitting the course booking form. "No Show" regardless of any reason will be
charged 100% of the fee.
Other: South Staffordshire and Shropshire Healthcare NHS FT makes every effort to run the workshop/course as planned and
scheduled. However we reserve the right to change the timings/content/trainer/delivery date/change the venue/location/any related
aspects at any time and without prior notice from that published.
On occasions, and only due to circumstances beyond our control, we reserve the right to cancel the course at any time and without prior
notice from that published, in such event you will be offered a place at rescheduled date, in case you do not wish to take this up and
wish to cancel your booking you will be given a full refund. In any case/s we shall not be liable for any losses occurring from the above
or any other losses.
We pride ourselves on developing and delivering high quality training courses and related material to our clients. Our courses are NHS
developed and delivered by professional trainers with clinical backgrounds and have been rigorously assessed and mapped to national
best practice guidelines, please do not hesitate to contact us to ask/clarify any related information. We will send you all correspondence
via email on the email address you provide to us in this booking form unless specifically requested by you.
By completing and submitting this Course Booking Form I /we agree (we is a term used for more than one delegates listed in this form
and applies to each delegate) that I / we have read and agree to the Terms and Conditions and this agreement fully as detailed in this
document. This Course Booking Form becomes a binding agreement once submitted to us either via email or post. Nothing in this
document affects your statutory rights.
The information you provide us will not be forwarded/sold to any other party however we may use this information to send
you any future information about our DMI training – please tick the box below if you do not want us to contact you.