PAH - Course and study day booking form

Course and study day booking form
Who are you booking this course for?*
Personal Details

Please provide your personal details below.
Personal Details

As the course booker please provide your details below and then add the course attendees when prompted.
Personal Details

As the course booker please provide your details below as you will be our point of contact. You will be able to add additional attendees at the next stage of the form.
Name*

TitleFirst NameLast Name
Address for Correspondence*

Address Line 1

Address Line 2

City/TownCounty

Post CodeCountry
Preferred contact phone number*
Is this your work, home or mobile?*
Email*
example@example.com
Position held*
Other:
(please specify)
Organisation : *
Practice Name / Team:
PCN Name:
Particular requirements: (eg diet, access, learning adjustments)*
Please give any dietary, access or learning adjustment details
Where did you hear about this course?*
Other:
(please specify)
Keeping in touch

We would like to be able to keep you informed about our education services, but if we don’t have your permission, we cannot get in touch with you to share regular updates about education sessions/study days and our prospectus.
Would you like to hear from the EDUCATION department (only) by EMAIL?*

YesNo
Would you like to hear from the EDUCATION department (only) by POST?*

YesNo
If you would also like us to share our LATEST NEWS, CAMPAIGNS and INFORMATION using the methods of communication you have said yes to above, please confirm here:*

YesNo
Rest assured, we never share, swap, rent or sell our customers’ details to other charities or third parties for marketing purposes. You can read how we manage and respect your data in our Education Customer Privacy Notice at www.pah.org.uk/privacy

If you’d like to change your permissions at any time please contact our Education Team on 01372 461988 or education@pah.org.uk
Click next to start adding attendee(s).

Course attendee 1

Please enter the course attendee details below for the person you are booking onto this course with you or who you are booking this course on behalf of. If you are booking more than 4 additional people on to a course please call us on 01372 461988.
Name*

PrefixFirst NameLast Name
Position held*
Other*
(please specify)
Organisation : *
Attendee Email address
example@example.com
Particular requirements: (eg diet, access, learning adjustments)*
Please give any dietary, access or learning adjustment details
Would you like to book any other course attendees?*

YesNo

Course attendee 2
Name*

PrefixFirst NameLast Name
Position held*
Other*
(please specify)
Organisation : *
Attendee Email address
example@example.com
Particular requirements: (eg diet, access, learning adjustments)*
Please give any dietary, access or learning adjustment details
Would you like to book more people?*

YesNo

Course attendee 3
Name*

PrefixFirst NameLast Name
Position held*
Other*
(please specify)
Organisation : *
Attendee Email address
example@example.com
Particular requirements: (eg diet, access, learning adjustments)*
Please give any dietary, access or learning adjustment details
Would you like to book more people?*

YesNo

Course attendee 4
Name*

TitleFirst NameLast Name
Position held*
Other*
(please specify)
Organisation : *
Attendee Email address
example@example.com
Particular requirements: (eg diet, access, learning adjustments)*
Please give any dietary, access or learning adjustment details

Course Details & Payment

This page shows any specific course details and payment
Type of course*
Dates and Times (Advanced Communication Skills F2F Training - FACE TO FACE Model)*
Date and Times (Advanced Communication Skills Training - New blended learning (remote) model )*
Dates and Times (Altered Airways in end of life care) *
Dates and Times (Assessing and recording mental capacity)*
Date and Times (Becoming a Dementia Friend)*
Date and Times (Bereavement, change and loss for children and young adults - A practical and interactive guide)*
Date and Times (Bereavement, loss and change for care homes)*
Date and Times (Bereavement, loss and change for learning disability homes)*
Date and Times (Bereavement, loss and change for domiciliary care agencies)*
Date and Times (Cultural sensitivity & inclusion in end of life care)*
Date and Times (End of Life Care Out of Hours - Caring with Confidence course)*
Date and Times (FASP)*
Does your place of work have an ultrasound machine?*

YesNo
If yes, will you be able to bring it to the training?*

YesNo
If you have an ultrasound machine at work and are able to bring it, please confirm the make and model
Date and Times (Frailty Study Day )*
Date and Times (Foundation Communication Skills for care homes, domiciliary care agencies and learning disability homes) )*
Dates and Times (Helping children and young people before and after the death of a significant adult)*
Date and Times (Male Catheterisation)*
Date and Times (Managing fungating wounds at end of life)*
Dates and Times (Managing Important Conversations)*
Date and Times (Managing Palliative Care Emergencies)*
Date and Times (Motor Neurone Disease (MND) study day)*
Date and Times (Namaste)*
Dates and Times (Planning Ahead and difficult conversations)*
Dates and Times (SAGE & THYME)*
Dates and Times (Self care and Resilience)*
Date and Times (Social and Emotional Aspects of palliative care - Study day)*
Date and Times (Staff Wellbeing for care homes)*
Date and Times (Staff Wellbeing for learning disability homes)*
Date and Times (Supporting people with a learning disability at the end of life)*
Dates and Times (Symptom Management at the end of life (for Nurses)
Date and Times (Syringe Pump in end of life care - full 3 hour)*
Dates and Times (Syringe Pump in end of life care - Refresher session)*
Dates and Times (Understanding and responding to bereavement)*
Date and Times (Venepuncture & Phlebotomy)*
Date and Times (Verification by nurse of expected death)*
Date and Times (Staff Wellbeing for domiciliary care agencies)*
Dates and Times (What is Hospice Care?)
Date and Times (Whose notes are they anyway?)*
I would like to pay

Online nowBy Invoice
I would like to pay*

Online nowBy InvoiceI have a code provided by my employer
SDH&C
Please note:

The following training is currently not funded by Surrey Downs Health & Care:

Venepuncture and Phlebotomy
Male Catheterisation
ECEPC
FASP
Advanced Communications Skills

Please contact your line manager to find out more information on how to access this training.

Your training provider, Surrey Downs Health & Care will be charged for this training. Unless the place on the course is cancelled via email to education@pah.org.uk 48 hours or longer before the training date, the training fee will still be applicable. Surrey Downs Health & Care reserve the right to recuperate any charges from the learner, which have been incurred for non-attendance or cancellation.

STH
Please note:

The following training is currently not funded by Surrey Training Hub:

ECEPC
FASP
Advanced Communications Skills

Bookings from Care Homes are currently not permitted with Princess Alice Hospice using STH-PAH booking code. Please contact Surrey Training Hub directly to see training on offer for Care Homes.

Your training provider, Surrey Training Hub will be charged for this training. Unless the place on the course is cancelled via email to education@pah.org.uk 14 days or longer before the training date, the training fee will still be applicable. Surrey Training Hub reserve the right to recuperate any charges from the learner, which have been incurred for non-attendance or cancellation.
Please enter the code provided by your employer if you have one
Terms and Conditions*
Payment by Invoice

If you are unable to pay online, please request an invoice here.
Name*

TitleFirst NameLast Name
Job Title*
Department*
Organisation*
Address for Correspondence*

Address Line 1

Address Line 2

City/TownCounty

Post codeCountry
PO number. Please note that require a PO or reference number for ALL invoices. If one cannot be provided we require your finance department email address here. Please contact education@pah.org.uk if you would like to discuss*
(If applicable)
Phone Number*
Email*
example@example.com
Payment

Your payment will be processed by Stripe who use the strictest payment processing procedures and has been audited and certified to PCI Service Provider Level 1.
Total cost

Should be Empty:

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Course and study day booking form

Personal Details

Personal Details

Personal Details

Course attendee 1

Course attendee 2

Course attendee 3

Course attendee 4

Course Details & Payment

Payment by Invoice

Payment