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UKCPA Conference Registration Form
24 - 25 November, The Queens, Leeds
Name
*
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Last
Title
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Other, please state
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Place of work
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Address for correspondence
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Samoa
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Algeria
Angola
Benin
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Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
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Libya
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Mali
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Morocco
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Niger
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Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Phone
*
Email
*
Please confirm your email address or specify an additional address we could contact you on
*
Are you a first time attendee at a UKCPA meeting?
Yes
No
Membership status
*
UKCPA member
GHP member
APTUK member
PCPA member
BPSA member
Non member
UKCPA application to follow
If your application is not received within 7 days you will be charged the non members rate.
Membership number
I am a
*
Work Session/Plenary Speaker
Lead Poster Presenter
Exhibitor
Delegate
Industry Delegate
Press Representative
Conference dinner attendee only
Friday 10.10 - work session 1 options: 1st Choice
Please select
Identifying and prioritising medication safety issues
How to effectively measure medication safety
Managing risks with medicines in e-prescribing
Hierarchical vs network leadership
I do not wish to attend a session
N/A
If your preferred worksession does not appear, it means it has reached maximum delegate numbers
Friday 10.10 - work session 1 options: 2nd Choice
Please select
Identifying and prioritising medication safety issues
How to effectively measure medication safety
Managing risks with medicines in e-prescribing
Hierarchical vs network leadership
I do not wish to attend a session
N/A
If your preferred worksession does not appear, it means it has reached maximum delegate numbers
Friday 12.15 - work session 2 options: 1st Choice
Please select
Different perspectives on change
I do not wish to attend a session
N/A
If your preferred worksession does not appear, it means it has reached maximum delegate numbers
Friday 12.15 - work session 2 options: 2nd Choice
Please select
Different perspectives on change
I do not wish to attend a session
N/A
If your preferred worksession does not appear, it means it has reached maximum delegate numbers
Friday 14.30 - work session 3 options: 1st Choice
Please select
Speed coaching: Developing yourself and others
Delivering multidisciplinary team training and education
Ten things to do to be a safe and effective prescriber
I do not wish to attend a session
N/A
If your preferred worksession does not appear, it means it has reached maximum delegate numbers
Friday 14.30 - work session 3 options: 2nd Choice
Please select
Speed coaching: Developing yourself and others
Delivering multidisciplinary team training and education
Ten things to do to be a safe and effective prescriber
I do not wish to attend a session
N/A
If your preferred worksession does not appear, it means it has reached maximum delegate numbers
Faculty Assessment slot (16.30 - 18.30)
I would like to book a case based 1-2-1 discussion
I would like to book an informal portfolio review
I do not need to book a slot
We will contact you to arrange your precise meeting time/room prior to the conference.
I would like to attend the GSK Satellite Meeting: Optimising the use of inhalers in COPD, at 16.30
*
Yes please
No thank you
This meeting has been organised by GSK.
Saturday 11.00 - work session 4 options: 1st Choice
Please select
Developing your critical appraisal skills
How to present your research and audit at conferences
How to develop a multitude of skills through conducting research
In it to win it: Writing a research grant application
I do not wish to attend a session
N/A
If your preferred worksession does not appear, it means it has reached maximum delegate numbers
Saturday 11.00 - work session 4 options: 2nd Choice
Please select
Developing your critical appraisal skills
How to present your research and audit at conferences
How to develop a multitude of skills through conducting research
In it to win it: Writing a research grant application
I do not wish to attend a session
N/A
If your preferred worksession does not appear, it means it has reached maximum delegate numbers
Saturday 13.00 - work session 5 options: 1st Choice
Please select
Introduction to Assertiveness
How to think creatively to improve patient care
Improving Discharge Medication Prescriptions
Making the most of the whole pharmacy workforce
I do not wish to attend a session
N/A
If your preferred worksession does not appear, it means it has reached maximum delegate numbers
Saturday 13.00 - work session 5 options: 2nd Choice
Please select
Introduction to Assertiveness
How to think creatively to improve patient care
Improving Discharge Medication Prescriptions
Making the most of the whole pharmacy workforce
I do not wish to attend a session
N/A
If your preferred worksession does not appear, it means it has reached maximum delegate numbers
Delegate registration options
*
Student registration, 2 day non residential (excluding accomm/evening meal). Must be a UKCPA member. Not available to qualified healthcare professionals
2 day non residential (excluding accomm/evening meal)
Day delegate Friday only
Day delegate Saturday only
I am an industry representative and have completed the relevant section below
I am not a delegate, I wish to attend the conference dinner only
Fees start from £75. Please refer to the conference page on the UKCPA website for clarification of charges
Conference dinner reservation
*
I do not wish to book a place at the conference dinner
I would like to reserve a place for myself at the conference dinner
I would like to reserve 2 places at the conference dinner, 1 for myself and 1 for my guest, named below:
Conference dinner ticket price: £40 each, to include pre dinner drinks, 3 course conference dinner and music afterwards
Industry representative registration options
Day delegate Friday only
Day delegate Saturday only
2 day non residential (excluding accomm/evening meal)
Please note, industry representatives are only eligible for the members rate if their company is a current corporate member of the Association or is exhibiting or sponsoring this event
Industry day delegate fees:
Friday: £550, Saturday: £450.
2 day non residential package: £900
To book a place at the conference dinner, please use the section above
Dietary requirements, please state
ie, vegetarian, vegan, halal, kosher, allergies.
Special needs, please state
ie, wheelchair access, hearing loop, other
Payment option
*
I will forward a cheque within 7 days
I will forward a bank draft within 7 days
I require your bank details so I can make a direct credit transfer
I require an invoice for my employer/Trust. An invoice is a request for payment and will not be sent after payment has been received
I wish to pay by debit/credit card. I will call the UKCPA office within 7 days
Cheques and bank drafts should be made payable to 'UKCPA'
I am paying by cheque, card, bankdraft or direct credit and require a receipt
Yes, please send me a receipt of my payment
Receipts will be sent to the email address given above. Receipts will on be issued once full payment has been made. Receipts will not be issued where an invoice has been raised.
If an invoice is required, please detail to whom and where the invoice should be sent
First
Last
Invoices will only be sent to Trusts/Employers. The UKCPA no longer issues invoices to individuals.
Email address of finance dept
The UKCPA prefers to email invoices
Purchase order number/reference code
Without this number/reference, your Trust will not settle our invoice. Please be reminded that as the individual attending this event, you are liable to settle your fee should your Trust reject the invoice
Finance Dept address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Payment using this method should be made upon immediate receipt of invoice
Are you self funding your attendance at this event?
Please select
Yes
No
Ie, you are not claiming your attendance fee back from your employer or a sponsor
UKCPA’s Cancellation Policy. Please select 'Yes' to confirm that you have read and understood this policy.
*
Please select
Yes
We regret that we have to make a charge for cancelled registrations. If you notify us of the cancellation of your reserved place giving six weeks or more prior notice to the event, 25% of the fee will be retained. From six to three weeks prior to the event, 50% will be retained. If between twenty and eight days notice is given of the cancellation for your reserved place for a UKCPA event, 75% will be retained. There is no refund for non-attendance or cancellations made less than one week (7 days) prior to the event, whereupon the full fee will remain payable. The Association reserves the right to cancel meetings and to return the registration fee. The Association cannot be responsible for any losses resulting from such cancellation, however caused.
How did you hear about this event?
UKCPA website
UKCPA discussion board notice
In Practice announcement or insert
UKCPA Conference 2016, supported by the GHP
Event advertising flyer
Email from the UKCPA
Email forwarded from a third party
UKCPA Facebook page
UKCPA Twitter feed
UKCPA LinkedIn group
UKCPA In Focus (e-bulletin)
Journal, ie PJ, Chemist & Druggist, Clinical Pharmacist
Recommended by a colleague, friend or manager
UKCPA Stand at another conference, ie, RPS, CPC
Other, please state
Please check all that apply
The UKCPA Clinical Pharmacy Training Day is taking place at the same venue on the Thursday before this conference commences. Would you like us to send you further information?
*
Yes please
No thank you
UKCPA Clinical Pharmacy Training Day, 23rd November 2017, The Queens, Leeds
By clicking on the submit button, you are confirming that you wish to reserve a place at the symposium as specified above and will be bound by our terms and conditions.
*
I understand
Please include any important information or comments here