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 *

Title First Name Last Name
Address for Correspondence *

Address Line 1

Address Line 2

City/Town County

Post Code Country
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? *

Yes No
Would you like to hear from the EDUCATION department (only) by POST? *

Yes No
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: *

Yes No
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 *

Prefix First Name Last Name
Position held *
Other *
(please specify)
Organisation : *
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? *

Yes No

Course attendee 2
Name *

Prefix First Name Last Name
Position held *
Other *
(please specify)
Organisation : *
Particular requirements: (eg diet, access, learning adjustments) *
Please give any dietary, access or learning adjustment details
Would you like to book more people? *

Yes No

Course attendee 3
Name *

Prefix First Name Last Name
Position held *
Other *
(please specify)
Organisation : *
Particular requirements: (eg diet, access, learning adjustments) *
Please give any dietary, access or learning adjustment details
Would you like to book more people? *

Yes No

Course attendee 4
Name *

Title First Name Last Name
Position held *
Other *
(please specify)
Organisation : *
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 *
Date and Times (Saying goodbye from a distance) *
Date and Times (Helping children and young people before and after the death of a significant adult) *
Date and Times (Oncology Study Day) *
Date and Times (Advanced Communication Skills Training - New blended learning (remote) model ) *
Dates and Times (Resilience) *
Dates and Times (Self care) *
Date and Times (Whose notes are they anyway?) *
Date and Times (Supporting people with a learning disability at the end of life) *
Date and Times (Engaging with hard to reach groups) *
Date and Times (SAGE & THYME via ZOOM) *
Date and Times (SAGE & THYME FACE TO FACE) *
Date and Times (WORKING WITHIN BOUNDARIES AND SELFCARE) *
Date and Times (Becoming a Dementia Friend) *
Date and Times (Staff Wellbeing for care homes) *
Date and Times (Staff Wellbeing for domiciliary care agencies) *
Date and Times (Staff Wellbeing for learning disability homes) *
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 (Foundation Communication Skills for care homes, domiciliary care agencies and learning disability homes) ) *
Dates and Times (Symptom Management at the end of life (for Nurses)
Date and Times (Male Catheterisation) *
Date and Times (Venepuncture & Phlebotomy) *
Date and Times (Advanced Communication Skills Training) *
Date and Times (Syringe Pump in end of life care - full 3 hour) *
Dates and Times (What is Hospice Care?)
Dates and Times (Syringe Pump in end of life care - Refresher session) *
Date and Times (Bereavement, change and loss for children and young adults - A practical and interactive guide) *
Dates and Times (Bereavement, loss and change during Covid 19 - A teachers guide
Date and Times (Verification by nurse of expected death) *
Date and Times (Cultural sensitivity and inclusion in end of life care - full day) *
Date and Times (Managing fungating wounds at end of life) *
Date and Times (Namaste) *
Date and Times (Spiritual distress and assessment) *
Dates and Times (Safeguarding and mental capacity at end of life - Level 2) *
Dates and Times (Having difficult conversations over zoom/telephone) *
Dates and Times (Advance care planning (ACP) and difficult conversations) *
Dates and Times (Assessing and recording mental capacity) *
Dates and Times (Understanding and responding to bereavement) *
I would like to pay

Online now By Invoice
I would like to pay *

Online now By Invoice I have a code provided by my employer
Please enter the code provided by your employer
Terms and Conditions *
Payment by Invoice

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

Title First Name Last Name
Job Title *
Department *
Organisation *
Address for Correspondence *

Address Line 1

Address Line 2

City/Town County

Post code Country
PO number
(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