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 *

Prefix 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 : *
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 us by email? *

Yes No
Would you like to hear from us by post? *

Yes No
Would you like to hear from us by phone? *

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 *

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

Course Details & Payment

This page shows any specific course details and payment
Type of course *
Date and Times (SAGE & THYME) *
Date and Times (Male Catheterisation) *
Date and Times (Venepuncture & Phlebotomy) *
Date and Times (Advanced Communication Skills Training) *
Date and Times (Artificial feeding and dysphagia management) *
Date and Times (McKinley Syringe Pump) *
Date and Times (Helping Children & young people before & after bereavement) *
Date and Times (Symptom management including the use of methadone study day) *
Date and Times (Management of Malignant Spinal Cord Compression (MSCC) – care and management) *
Date and Times (Verification by nurse of expected death) *
Date and Times (End of Life care in a multi-cultural society) *
Date and Times (Managing fungating wounds at end of life) *
Date and Times (Namaste) *
Date and Times (Spiritual distress and assessment) *
Date and Times (Whose notes are they anyway) *
Dates and Times (Working with people with dementia - an experiental workshop) *
Dates and Times (QCF Level 3 Award in awareness of end of life care *
Dates and Times (Safeguarding and mental capacity at end of life - Level 2 or 3) *
Dates and Times (Advance care planning (ACP) and difficult conversations)
I would like to pay

Online now By Invoice
I would like to pay *

Online now By Invoice
Terms and Conditions *
Payment by Invoice

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

Prefix 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