KOGS National Student Conference 2020

22^nd February 2020

David Weatherall Building, Keele University, Keele, ST5 5BG

Register for this Conference

To ensure that confirmation of place is not delayed, could you kindly state if you are registering and paying for this course/event for yourself or on behalf of someone else?

I am registering and paying for myself

I am registering and paying on behalf of someone

Please provide the DETAILS OF THE STUDENT/DOCTOR on behalf of whom you are registering and paying:

Title

Gender

Please ensure that you enter your name accurately since it will be printed on your name badge and certificate.

Forename

Surname

Address

Would you like to attend the conference dinner?

Are you a

Hospital

University

Year of Study

Pin code/Post code/ Zip code

Landline Number

Your registration is not complete and your place in event will not be confirmed until all fields are completed.

Please provide YOUR DETAILS so that we can match the payment with the candidate's details in our system.

Forename

Surname

Address

Country

Pin code/Post code/ Zip code

Phone number (including country code if outside the UK)

Please state your relation to this candidate