EPNS Masterclass 2024 Registration form for Two People

COMPLETE THIS FORM to register for TWO people to attend the EPNS Masterclass with accommodation included (785 Euros) OR with no accommodation included (600 Euros).
Delegates are encouraged to register as a “couples” (TWO people); a senior mentoring clinician and a mentee/leader of tomorrow. Couples do not necessarily have to work at the same hospital but must have a mentor/mentee connection.

You are completing this form for a “couple”, i.e. for 2 people as a mentor/mentee couple

If instead you would like to register for one person only, you are most welcome. Please complete the form entitled 'EPNS Masterclass 2024 Registration form for One Person (450 Euros or 350 Euros with NO accommodation)'

All fields marked (*) are mandatory.

MENTOR (senior mentoring clinician) information

Mentor Title(*)

Mentor First name(*)

Mentor Last name(*)

Mentor Email(*)

Mentor Mobile Telephone Number(*)

Mentor Work Address(*)

Mentor Country 1(*)

MENTEE (young leader of tomorrow, suggested under 45 years old, with a clinical practice in paediatric neurology and active in research and teaching) information

Mentee Title (*)

Mentee First name (*)

Mentee Last name (*)

Mentee Email (*)

Mentee Mobile Telephone Number (*)

Mentee Work Address (*)

Mentee Country (*)

MENTOR and MENTEE Masterclass information

What time approximately will you both arrive on Wed 18 September 2024 (the masterclass begins first thing on Thurs 19 Sept 2024)? Please tick the appropriate box (*)

provide further details about arrival time, if needed ...

Will you both be attending the optional social event on Thursday 19 September 2024 for an extra cost of 60 Euros per person? (Kettle's Yard and dinner at the Eagle pub) Note: drinks at The Eagle are NOT included in this price. Guests need to purchase their own drinks from the bar? (*)

Will you both be attending the conference dinner on Friday 20 September 2024 at Corpus Christi (this is included in the registration fee)? (*)

Do you have any special dietary requirements? (*)

If special dietary needs, please give details ...

Do you have any special needs (e.g. wheelchair, etc.)? (*)

If yes, please give details ...

We are both EPNS members and we have both paid our 2024 EPNS Membership fee (MANDATORY. Will be verified)

We would like pay the following registration fee: (*)

We understand the registration fee of 785 Euros includes accommodation for 3 nights (18,19,20 September 2024) for 2 people at either at Corpus Christi, St Catharine’s College or Gonville and Caius College in en-suite single rooms and that these are student rooms and can be quite basic (This field is mandatory therefore, please tick even if not registering for accommodation to be included)(*)

We will need accommodation for additional nights (cost 100 Euros per night per person) (*)

If yes, please give details ...

How will you be paying? Payment details will be sent in the automatic acknowledgement email.(*)

We have read, understood and accept the EPNS Masterclass Terms and Conditions [+]

We understand to confirm this reservation, we must pay the registration fee (plus fee for extra nights accommodation and Thursday social evening event if applicable).