REGISTRATION (Please print, then post or fax)

File No.......

 

Title: Mr/Mrs/Miss/Ms/Dr............................

Surname:................................................

Forename:...............................................

Address:.................................................

.............................................................

.............................................................

County:..................................................

Post Code:..............................................

Email:..................................................

Tel Work:.............................................

Tel Home:............................................

Mobile:................................................

Tick number to be used in the directory

 Main Therapy:......................................

Qualifications**:..................................

Professional body**:.............................
** It is assumed that you are a professionally established, insured and/or qualified healthcare practitioner including a physical modality in your practice. Any doubts about this must be raised with The Upledger Institute in case the signing of an appropriate waiver is required.

I understand that all of the above information will be relied upon in confirming my place and setting up my file.

Signature ................................................................

Workshop you wish to attend: (Please tick appropriate)  

CSTI CSTII SERI SERII ADVI ADVII CSTP Other

Dates of course: …………………..   Location: …………............ Deposit enclosed:   £200.00 

If this is your first Upledger UK workshop, how did you hear about us?...................................

Method of payment:   Cheque .......   Credit card .......   Other (please specify)....................

Visa [   ] Mastercard [   ] Delta [   ] Switch [   ] Electron [   ] Solo [   ]     

                                                 

Start date......../........   Expiry date........./........  Issue date (Switch only)........./........

Card Security Code (all cards).............

Name (as it appears on card) .....................................................................................    

Address (where card is registered) ..............................................................................    

................................................................................................Post Code ...............

Signature ......................................................................................................

You may also debit my credit card for the balance one month before the workshop [   ]

The Upledger Institute UK   2 Marshal Place, Perth PH2 8AH Scotland
 Tel: 01738 444404         Fax: 01738 442275       e-mail: mail@upledger.co.uk          www.upledger.co.uk