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ATLS


Isle of Wight

Please Complete and Return this Reply Slip to:
Lyn Elderfield – Course Co-ordinator

Medical Education Centre

NHS Isle Of Wight

St Mary’s Hospital, Newport

Isle Of Wight PO30 5TG

Tel: 01983 534 231 Fax: 01983 521 963

e’mail: lyn.elderfield@iow.nhs.uk

APPLICATION TO ATTEND THE ATLS COURSE THAT RUNS FROM

27th – 29th June 2012. I ENCLOSE MY PASSPORT SIZE PHOTO AND A CHEQUE FOR £625 MADE PAYABLE TO “NHS Isle of Wight”
(You will be responsible for making your own accommodation arrangements. There is some hospital accommodation available on site. You will need to contact Western Challenge by ‘e’mail to zoe.gardner@westernchallenge.co.uk for ‘on site’ accommodation or contact the Isle of Wight Tourist Board 01983 813 813)
Name: ……………………………………… DOB: .……………...
GMC No: …………………………….
Address for correspondence (including post code):
……………………………………………………………………………….
……………………………Tel: ……………………’e’mail……………….
Hospital ………………………….……………………………………….
Department………………………………………………………………..
Current Position…………………………………………………………
Signed………………………………………………………………………

………………………………………………………………………………


Payment must be made with this application.

Places will be allocated on a ‘first come, first served’ basis.

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