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Booking Form

Achieving a smoke-free future for Gwent

Please return this completed form to Samantha Clarke (details below) by
Thursday 1st September 2011, as places will be allocated on a first come first
serve basis
Dr Mr Mrs Ms Miss Other
First Name Surname
Job Title
Department
Organisation
Address

Postcode
Telephone Number
Email
Fax
I am a wheelchair user
I require future material in large print
I require a hearing loop
I have certain dietary requirements (please state below)

Please state any other requirements (please state below)

Important Information
Please Note that we may film, record or photograph all or part of the event, and that footage, photography
or audio may be broadcast afterwards and used in a professional context.

Public Health Wales reserves the right to make changes to the programme or speakers should this become
necessary.

Please note there will be a charge for non-attendance.
Please return completed forms to
Samantha Clarke, Project support Officer, Public Health Wales, Llanarth House,
1 Newbridge Gateway, Bridge Street, Newbridge, NP11 5GH

Direct Line: 01495 241218 Fax: 01495 241202 E-mail: Samantha.clarke@wales.nhs.uk