Application form
(please print and complete by hand)

Name

Address






Phone no.

E-mail
(correspondence will be by e-mail wherever possible)

Waged/Unwaged
   (please delete one)

Work role (if applicable)

Please indicate any special dietary requirements for meals

.

.......................................................

Please reserve a place for me at the conference.

I am/am not interested in joining others for dinner at a local restaurant on Friday 15th (cost not included in conference fee).

Signed …………………………………………………

Costs for 2 days (including lunch, tea and coffee): £95 waged, £40 unwaged

Please return this form, including cheque for full amount payable to Midlands Psychology Group, to:-

Penny Priest
South East Shropshire Community Mental Health Team
Northgate Health Centre
Bridgnorth Hospital
Bridgnorth
WV16 4EN