INTERNATIONAL ART THERAPY CONFERENCE



Finding Spaces, Making Places: Exploring social and cultural space in contemporary Art Therapy practice.

Wednesday 13th – Saturday 16th April 2016

|REGISTRATION FORM |

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|*Full Name: | |

|*Department & Organisation: | |

|Postal address | |

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|*E-mail address: | |

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|Contact Telephone No: | |

|Special Requirements: | |

|(e.g. disabled access, special dietary requirements) | |

*Please note that the starred details will appear on our attendance list to be distributed to delegates.

Registration options& fees (please tick next to the appropriate option/s)

|EARLY REGISTRATION |The whole conference |£400 | |

|(before 31st January 2016) |(13-16/4/2016) | | |

| |Afternoon registration, welcome & keynote |Free to all | |

| |speakers (13/4/2016) |delegates | |

| |Day 1 (14/4/2016) |£200 | |

| |Day 2 (15/4/2016) |£200 | |

| |Day 3 (16/4/2016) |£200 | |

| | | | |

|FULL FEE |The whole conference |£500 | |

| |(13-16/4/2016) | | |

| |Afternoon registration, welcome & keynote |Free to all | |

| |speakers (13/4/2016) |delegates | |

| |Day 1 (14/4/2016) |£250 | |

| |Day 2 (15/4/2016) |£250 | |

| |Day 3 (16/4/2016) |£250 | |

| | | | |

|CONCESSION* (Students/Unwaged) |The whole conference | | |

| |(13-16/4/2016) | | |

| |Afternoon registration, welcome & keynote |Free to all | |

| |speakers (13/4/2016) |delegates | |

| |Day 1 (14/4/2016) |£100 | |

| |Day 2 (15/4/2016) |£100 | |

| |Day 3 (16/4/2016) |£100 | |

*Concession rate places are limited and proof of status will be required

All pages of this completed form and any remittance should be returned to:

Department of Social, Therapeutic & Community Studies, 21-23 St James, Goldsmiths, University of London, SE14 6NW, UK or by email to arttherapyconference2016@gold.ac.uk

Print Name ……………………………………………………………

Signed …………………………………………………………………

Date …………………………………………………………………….

|Delegate name: | |

PAYMENT METHODS

CHEQUES should be made payable to “GOLDSMITHS”

If you would like us to INVOICE your institution for the above amount, please complete the information requested below.

Name of person attending conference.……………………………………………….

Invoice address.………………………………………………………………………….

…………………………………………………………………………………………

Your purchase order reference number ……………………………………………………

|CARD HOLDER’S DETAILS |

|Name of card holder | |

|Type of credit/debit card: e.g. Visa, Mastercard | |

|Full name as displayed on the card: | |

|Card number (the long number in the centre of the card): | |

|Card issue date (mm/yy): | |

|Card expiry date (mm/yy): | |

|Debit card issue number: | |

|Security number (last 3 digits on back of card) | |

|CREDIT/DEBIT CARD (those shown below are the ONLY cards we accept) |IMPORTANT |

| | |

| | |

| |Please ensure that your card is|

| |valid for all payments |

|[pic] | |

|We are UNABLE to accept AMERICAN EXPRESS or DINERS CLUB | |

|[pic][pic] | |

Payment will be withdrawn upon receipt. By signing this form you are giving permission for Goldsmiths, University of London to deduct the above amount from your card to pay for attendance at the Art Therapy Coneference 2016 If your card is not issued in the UK, the transaction will be in your own currency and will be based on Reuters Wholesales Interbank exchange rate plus 3% international conversion margin to replace the charge from your card company. If your card is not issued in the UK and you choose to pay in GBP then please tick this box □. You will be subject to a conversion fee or charge by your card company related to the value of the transaction. Please note: Refunds will only be processed if asked 4 weeks prior to the Conference.

Signature of card holder: _________________________

Date: __________________

N.B. The person signing this form must be the card holder. If you are sending this form via e-mail then please send an accompanying email to arttherapyconference2016@gold.ac.uk stating that Goldsmith’s, University of London is authorized to deduct the above amount.

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