ADVANCED TRAUMA LIFE SUPPORT COURSE (accredited by the Royal College of Surgeons)

10th & 11th March 2022

Chiltern Education Centre, Wycombe Hospital
Course Fee £650 - payable upon notification that place is held
To include course material, lunch & refreshments
To apply please PRINT the following required information:
Dr/Mr/Mrs/Miss/Ms/Other SURNAME
WAHEED
FORENAME MOHAMMED
PREFERRED NAME FOR BADGE MOE

You are required to register on the Royal College of Surgeons and provide your RCS contact number for the
course centre to submit when registering you on the course.
Please use the link below to register and note your RCS contact number
here: https://www.rcseng.ac.uk/register/

HOME ADDRESS 87 Tradewind Square. Apartment 10

L1 5BG
Liverpool, UK

POSTCODE L1 5BG
TEL 07493906613 (Mobile)
Email
mohammed.waheed@nhs.net

PLACE OF WORK
THE WALTON
CENTRE
POSITION SHO SPECIALITY
NEUROSURGERY
GMC/PIN DATE OF BIRTH
NO:7666177 16/06/1991
Do you have any specific dietary requirements?
To pay by debit/credit card please call the cashiers office on 01296 316603 or 01494 734391 quoting the
course title and date. Please do not make payment by card until it has been confirmed that a place is being
held for you. Refunds may take some time to process. Payment is then due at time of booking.
Cheques to be made payable to ‘Buckinghamshire Healthcare NHS Trust’.
Payment Enclosed  Payment via Cashiers x
Confirmation will be sent on receipt of application form and payment to confirm your place
Terms & Conditions of booking –Please read carefully.
As this is an intensive course, candidates need to have time to adequately assimilate the pre course
material. It is the candidates own responsibility to ensure appropriate study leave is booked, this is not a
valid reason for late cancellation. Should you withdraw within 8 weeks of the course commencement date or
fail to attend without a valid reason the full course fee of £650.00 is non-refundable. Cancellations/transfers
prior to 8 weeks will be subject to a £75 administration fee.
Manuals are sent out approximately 4 weeks prior to the start of the course.

I have read & fully understand the terms and conditions of booking x

External Candidate ATLS

 Signed M.W Dated 05

Please return to: Joanne Jackson, Office Manager, Room F84, Claydon Wing, Resuscitation Service, Stoke
Mandeville Hospital HP21 8AL ( 01296 316557 Fax: 01296 316250 * joanne.jackson19@nhs.net