Registration Form

REGISTRATION FORM (PLEASE WRITE OR TYPE CLEARLY)

FULL NAME

ADDRESS
Please give full postal address
TELEPHONE
EMAIL (Important)
ORGANISATION
DISABILITY & OTHER PERSONAL NEEDS
ARE YOU A WHEELCHAIR USER				YES		NO
WILL YOU NEED SIGN LANGUAGE SUPPORT				YES		NO
DIETARY REQUIREMENTS
CONFERENCE FEE	Statutory Sector organizations £100.00 per delegate	Third Sector organizations £25.00 per delegate			Private Sector organizations £250.00 per delegate
DETAILS FOR BACS PAYMENTS LLOYDS TSB BANK ACCOUNT	Account Name East Midlands Racial Equality Consortium		Account Number 01716967		Sort Code 30-95-21		Booking Reference Equality Conference

Please tick one workshop you wish to attend

Workshop 1 Disabilities	Workshop 2 Gender	Workshop 3 Race	Workshop 4 Faith	Workshop 5 Sexual Orientation	Workshop 6 Age

PLEASE MAKE ALL CHEQUES PAYABLE TO EMREC
Please note confirmation of registration will be sent out on receipt of cheque or BACS payments

RETURN REGISTRATION FORMS & CHEQUE PAYMENT TO :

EMREC
Conference Organizer
473B Alfreton Road Radford
Nottingham NG7 5NH

Telephone 07985 111233 Email info@vivitas.co.uk

FULL NAME