Course Booking Form for The Griffin InstituteFor any queries or issues please email courses@griffininstitute.org.uk or call 020 3958 0500Register and Pay by Card 1 2 3 4 Personal DetailsName* First Last Job Role/Training Grade*If ApplicableSpeciality*Employer*DeaneryIf ApplicableQualifications*Phone (Mobile)*Email* Special Requirements (eg: dietary or access needs)Training needs*ALSGBI Membership numberIf applicable Course BookingI would like to book the following course(s)ALSGBI Basic Robotic Surgical Skills3rd October 2021DeselectCost: £550.00 ALSGBI members will be refunded £50 once their membership is confirmed.Laparoscopic Skills Module D18th February 2022(12:30pm-16:00pm)DeselectCost: £100.00 Laparoscopic Skills Module C18th February 2022(08:30am-12:00pm)DeselectCost: £100.00 Laparoscopic Skills Module B17th February 2022(12:30pm-16:00pm)DeselectCost: £100.00 Laparoscopic Skills Module A17th February 2022(08:30am-12:00pm)DeselectCost: £50.00 BIARGS Basic Robotic Gynaecology Surgical Skills29th January 2022DeselectCost: £400.00 BIARGS Advanced Robotic Gynaecology Surgical Skills10th-11th December 2021DeselectCost: £1500.00 London Free Flap Course10th-11th March 2022DeselectCost: £750.00 Waiting ListThe following courses are fully booked, but if you would like to be added to the waiting list please select the courses and we will be in touch if places become available Laparoscopic Lower GI Surgery Laparoscopic Upper GI Surgery Basic robotic surgical skills Basic Microsurgery Course Booking Consent* I have read and agree to the Griffin Institute Booking Conditions In-vivo training course*I consent to the Griffin Institute retaining my contact information for liaison regarding my Home Office personal licence application - See section 2 of our Booking Conditions I consent Human cadaveric training course*I have read and understood the guidance for working with HTA licenced material at the Griffin Institute - See section 3 of our Booking Conditions. I consent ALSGBI Course* I consent for my contact details to be shared with ALSGBI admin to verify my membership If the course is fully booked, I consent for my contact details to be held on a waiting list by ALSGBI admin Almost there...Please select the following options as appropriate:* Select All I consent to the Griffin Institute retaining my contact information for the purpose of communication regarding the course(s) that I will be attending (compulsory)* I consent to the Griffin Institute retaining my contact information for the purpose of communication regarding future courses that may be of interest to me I consent to the Griffin Institute retaining my contact information in order to send regular Newsletters or updates, which may include communication regarding fundraising for their charitable purposes Where did you hear about this course?Please select all that apply Email from TGI Email from another organisation Twitter Facebook LinkedIn TGI Website PaymentBilling DetailsAddress of Credit/Debit Card Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Total £ 0.00 Payment Method*Card Details Cardholder Name Please Enter Your Card Details
