Technical Skills Lab, Fieldhouse, Bradford Royal Infirmary, BD9 6RJ

£600 inc VAT (inclusive of materials, refreshments and lunch)

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* Course Date - please select the date of the course you would like to book onto:

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* What is your full name?

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* Please provide your personal address:

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* Mobile number

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* Royal College of Surgeons of England membership number: please note we cannot accept a membership number from any other Royal College of Surgeons other than the one stated above. If you don't have an RCOS of England membership number please apply for one on their website. It is a 7 digit number and starts with the number 9.

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* What is your role/specialty?

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* What is your level/grade? e.g ST3, ST4 etc

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* To be eligible to attend this course you must have previous laparoscopic experience. Please click the box below to confirm your experience.

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* Please provide your work address:

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* During this course animal tissue models will be used as part of the learning materials. Due to the nature of the course we are unable to offer non animal tissue alternatives.
Please tick below to agree that you accept this.

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* Any disabilities or adaptions required:

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* Any dietary requirements:

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* Course Terms and Conditions

1) All course costs are per person including VAT (currently 20%)

2) Payment must be received within 2 weeks of confirmation of a space reservation which will be received via email. Failure to make payment within 2 weeks, or to communicate with the team regarding your intention to pay, will result in immediate removal from the provisional attending list.

3) Candidates’ full name is required.

4) Payment must be made in full before your booking is confirmed. We reserve the right to refuse attendance if payment is not made.

5) Cancellations 6 weeks prior to the course will result in a full refund. Cancellations 5 weeks prior to the course will result in a 50% refund. Cancellations less than 5 weeks prior to the course will result in no refund.

6) The Trust reserves the right to re-schedule course dates at short notice for example, insufficient places are booked to be cost effective or adverse weather conditions which could prevent staff/instructors from arriving at the centre.

I agree to the course Terms & Conditions

Following the completion of this form you will receive an email confirming a space reservation, if applicable, as well as the payment link. Payment must be made within 2 weeks of the email confirming your space reservation.

Please keep an eye out for this email in the next few days.

Thank you

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* Signed:

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* Date:

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