Registration Form

Ann Conroy Trust

Support Education and Research

For those living with

Chiari Malformation, Syringomyelia and associated conditions

British Syringomyelia Chiari Group

Meeting booking form


          Please complete, and return to the postal address provided or to info@annconroytrust.org


 

Name: _______________________________                              Position: _________________________

        

Unit: _________________________________                             Hospital: _________________________

   


Address:____________________________________________________________________________



              ____________________________________________________________________________

                  


     

 Postcode: _______________________                                            E-mail: __________________________

 


        I wish to attend the meeting to be held

            


on: ____________________________________                               at: ______________________________

 

    I wish to pay by:

  • BACS transfer: 40-52-40; 00011969
  • Paypal - info@annconroytrust.org
  • Cheque* (enclosed)

   * Payable to Ann Conroy Trust     

 

Thursday evening:


I will be attending the evening dinner/I will not be attending the evening dinner


Please note, you will need to confirm your intention to join the evening dinner with the hotel, when you make your room reservation


If you wish to consult with the group about any particular case please contact the Charity on info@annconroytrust.org in advance of the meeting. 
        

Ann Conroy Trust CIO

registered in England number 1165808

0300 111 000 4