Please ensure that fields marked * are completed.
SWPC Meeting date*
Attendee Name*
Delegate Category
Paying Delegate     Retired     Speaker
Name on Cheque, Debit/Credit Card or PayPal account (If different from attendee)

Job Title
Telephone*
Mobile
Address
Postcode
Email Address*
GMC Registration No.
Dietary Requirements
None     Vegetarian     Vegan     Gluten-free
Verification code - Case Sensitive!
(helps prevent automated submissions)

Information you submit to South West Paediatric Club will not be disclosed to any other organisation