SMART Assessor Training - Booking Form
January 23rd – 27th 2017
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Delegate fee before October 23 2016
Title:
£750
□
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Delegate fee after October 23 2016
First Name:
Job Title:
£785
□
Surname:
Organisation:
Address:
Postcode:
Telephone:
Mobile:
Email:
Details of neuro experience:
Special dietary or other requirements:
PAYMENT METHODS:☐
Cheque:
☐
Credit Card:
☐
(Please tick your chosen method)
Please make cheque payable to The Royal Hospital for Neuro-disability and send for the attention
of Phili Denning
Card number:
Valid From:
Expiry Date:
Security code:
Invoice:
PO or other reference number:
Invoicing address:
Accounts payable contact email:
☐
BACS
Sort code
Accounts payable contact tel:
Please send to the following Natwest Bank, RHN General Account
60 20 09
Account no.
4165 5273
Please send your BACS remittance form as confirmation of payment.
Your BACS reference:
If you are not self funding please confirm who has authorised your attendance at this course and the funding:
Name:
Position:
Contact email:
Tel:
General Information



Venue: The Royal Hospital for Neuro-disability, London.
Course fees include refreshments and lunch
Cancellations/refunds: A refund, less 20%
administration fee will be made if cancellations are
received in writing at least 4 weeks before the course.
We regret that regret that refunds cannot be made for
cancellation or non-attendance after this time. Substitute
attendees are welcome at any time.
Please return this form (one per applicant to:
Phili Denning,
Conference Organiser,
The Royal Hospital for Neuro-disability,
West Hill, Putney,
London SW15 3SW
Email: [email protected]
Please indicate with a tick that you, the delegate, and your manager have read and agree
with the information below:
Delegate
Manager
Full 5-Day SMART Accredited Assessor Training (Monday 23rd –
Friday 27th January 2017)
Full 5-Day SMART Accredited Assessor Course costs £785. Please
note that this charge also includes a £100 marking fee for the final
portfolio.
(Special rates for team bookings are available; please liaise with coordinator for
details.)
The course is very intensive
Full attendance of all 5 days is required, with the last day finishing at
4pm. In addition, there will be approximately 2 - 3 hours homework /
reading each evening.
Purchase of a SMART Kit is not included in the course fee.
A kit will be required to conduct future SMART assessments. Kits can
be shared between assessors within one unit.
For details of SMART kit costs please see the attached order form. Kits
can be ordered and paid for in advance of course attendance and
collected on the final day of the course. This will obviously save on
postage and packing costs.
Please ensure and orders for this are processed well in advance of the
course.
Please ensure you have read the course overview thoroughly and
understand all the work & study implications.
Delegate’s signature:
Manager’s signature:
Manager’s Name ( Please print)
Manager’s Tel:
Manager’s email:
Manager’s address:
All SMART courses are recognised by the College of Occupational Therapists.
The Hospital is able to supply information about local accommodation if requested.
Please Note:
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• Early bird booking by October 23rd 2016 for £750. Full payment must be received by Friday 13 January 2017.
We are unable to guarantee a place if payment has not been received by this date.
• Cancellations made at anytime more than two weeks in advance of the course will be charged at 20%.
Cancellations after this date will be charged at 100%.
• Failure to make payment may result in charges being incurred and possible disqualification from the entire course.
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• The RHN will hold your details for the purpose of marketing. This information will not be passed on to 3 parties.
• You do not need to wear uniform for the course as there will be no contact with patients
Sensory Modality Assessment & Rehabilitation Technique
Please note:

To purchase a complete SMART Kit or any individual items you must have completed the full 5 day Accredited
Assessor SMART training.

No items will be released before payment has been received, alternatively in special circumstances, the finance
department of your organisation can make contact indicating that the payment is being processed. If paying by
cheque, please allow 2 weeks for this to clear before your order will be despatched.
SMART KIT & SMART PRODUCTS ORDER FORM
Order Date
Accredited Assessor Name
(or Assessor in training)
Kit for use by (unit or individual)
Date Attended SMART training
Person Ordering (if different to above)
SMART Kit No.
(if purchasing individual items)
Delivery Address
Postcode
Invoice Details and Address
Postcode
Purchase Order No. or Reference No.
(if applicable)
Contact Telephone Number
Contact Email
PAYMENT METHOD – please select as appropriate
Cheque enclosed
NB: Please make cheques payable to „The Royal Hospital for Neuro-disability‟ and send for the attention of the SMART
Administrator. Please allow 2 weeks for the cheque to clear before your order will be despatched.
Sort Code
-
-
Account Number
BACS Transfer
Please send to: Nat West Bank Southfields, 250 Wimbledon Park Road, Southfields, London SW19 6NL
Account Name: The Royal Hospital for Neuro-disability
Sort Code:
60-20-09 Account Number: 41655273
Please pay direct into this account with “SMART Kit” as the reference.
IBAN:
SWIFT:
GB72NWBK60200941655273
NWBKGB2L
Credit Card
Card Number
Valid from
(MM)
Issue/Security No.
Invoice - will be sent to the address provided
(YYYY)
Expiry Date
(MM)
(YYYY)
ITEMS AVAILABLE TO ORDER – Please select all that apply
Cost (Each)
Behavioural Observation Computer Programme CD-ROM
£49.99
Complete SMART Kit (includes all items listed below)
£499.00
Qty.
Total Cost
Individual Replacement Items: To purchase any individual item, the purchaser must have access to a SMART Kit.
Manual/Techniques/Cards
£299.00
Copy of Manual
£99.00
Copy of Assessment Techniques
£99.00
Copy of Treatment Techniques
£99.00
Copy of Full set of Forms
£99.00
SMART DVD
£75.00
SMART Bag
75.00
Full set of Stimuli
£99.00
AF Switch
£40.00
Sub Total £
Postage & Packing (see below for details) £
Total £
Please send this order form and your payment (if applicable) to:
SMART Administrator
Research Department
Royal Hospital for Neuro-disability
West Hill
Putney
London SW15 3SW
Additional enquiries to:
Email:
[email protected]
Telephone: (+44) 20 8780 4500 extension 5140
Postage & Packing
Rate for United Kingdom orders
Rate for AF Switch & CD orders to UK
Rate for overseas orders
Rate for individual/additional SMART items
Rate for collection at end of course
- £30.00
- £3.00
- please call in advance of payment for quote
- please call in advance of payment for quote
- free