Perinatal Mental Health Research Conference

Registration Form
Title (e.g. Dr):       First Name:       Surname:      

Institution/Organisation:       Contact Address:       Telephone: E-mail:
            Yes No If yes, please specify:       CPN Midwife Health Visitor Service User

Do you have special dietary requirements: Are you a: Psychiatrist Social Worker Psychologist

General Nurse

Academic Researcher

Other (please specify):       Are you a member of the Marcé Society: Yes No

Registration Fees
Standard fee…... (£40.00) PhD student…… (£20.00)

The registration fee must be paid in full prior to the event in order to ensure registration for this conference. Confirmation of booking, with directions to the venue will be e-mailed to you.

Payment Options
Cheque enclosed, payable to Birmingham & Solihull Mental Health NHS Foundation Trust Amount £       Please invoice Invoice Address:      

Please return completed form via e-mail or post to: Shazia Hussain ( Perinatal Research Programme, R&I Dept, The Barberry, 25 Vincent Drive, Edgbaston, Birmingham B15 2FG

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