BAHT LEVEL 2 – The PIPJ
Provided by NES Hand Therapy Training
Wednesday 7th – Friday 9th September 2016
Application form
Please complete form in block capital letters
Name of applicant:
Profession:
Occupational Therapist  or Physiotherapist 
Number of years experience in Hand Therapy: 
BAHT no (if applicable)
Work address:
Completed BAHT Level 1?
Yes  No 
Correspondence address (if different):
Telephone number (work):
Fax number:
Telephone number (home):
Email address:
Do you have any dietary needs?
Yes  No  If yes please give details:
Do you have any physical / learning needs?
Yes  No  If yes please give details:
Amount:
£475 for BAHT members, £500 for non-BAHT members.
Payment options:
 Personal cheque.
Please send a cheque for the correct fee made payable to ‘St George’s Healthcare NHS Trust
FPX’ to:
Helen Griffin
Hand Therapy
St James Wing
St George’s Healthcare NHS Trust
Blackshaw Road
London SW17 0QT



Personal BACS transfer.
Sort code 60 21 29
Account number 58305580
Reference: FPX PIPJ
Credit/debit card by telephone.
Please call the cashiers office:
020 8725 2981/1632
Name on card:
Date of transfer: ___ /___ / 2014
Date of payment: ___ /___ / 2014
4 digit reference (given by cashier):
Invoice to employer.
Complete and return request form.
Payment notes:
 Places on this course are not secured until payment has been received
 If paying by BACS or credit/debit card by telephone, please email in advance to check there are still
places
 See attached document for cancellation policy
Signed: ………………………………………… Date: ……………………………………….....
Please return this form to Helen Griffin at the above address, or helenL.griffin@stgeorge’s.nhs.uk