Please use a separate form for each booking

Note: Places are only confirmed once payment has been received.

Full Name:
(in block capitals, Mr/Mrs/Miss/Ms/Dr)
Job Title:
School:
Address:
Tel:
Your email:
I wish to attend the following course:
Course Title:
Course No:
Course Date:
Course Fee:
(Cheques made payable to IPD)
Special dietary requirements:
Please note that IPD's usual policy is that full payment of the course fee is required as soon as possible after a provisional e-mail/telephone booking has been made (usually within five days). After this time, there is a risk that places may be released. Written confirmation of places will only be issued on receipt of full payment. No refund will be provided in the event of non-attendance or cancellation less than four weeks before the course takes place.
By sending this form you agree to the following:
"I consent to my personal details on this application form being used equally by GSA and HMC for purposes related to the provision of the joint IPD service."
Please send your payment to: IPD, 12, The Point, Rockingham Road, Market Harborough, Leicestershire LE16 7QU Tel: 01858 462477 Fax: 01858 461953