Date Form Rec:   Date Fees Rec:  UPDATE COURSE APPLICATION FORM Send to: -         Mrs Sharon Vaughan                           Course Administrator                           1 Winniford Close                           Chideock                           Dorset                           DT6 6SA   Tel:     07816814261                         E-mail:  sallytscott@googlemail.com or vaughan@chideock.co.uk Website: http://sites.google.com/site/westdorsethipcourse/   PLEASE RESERVE A PLACE ON THE 2012 UPDATE COURSE IN INFANT HIP ULTRASOUND   I ENCLOSE THE FEE OF £90 (cheques payable to Hip Ultrasound Education Fund)   Title:  (Dr/Mr/Mrs/Ms) ……………………………………………………………................................................................   Surname……………………………………………………………………………..........................................   First Name ……………………………………………………………………………......................................   Address (for correspondence) ………………………………………………………..............................   …………………………………………………………………………………………...........................................   …………………………………………………………………………………………...........................................   Postcode ………………………………………………………………………………......................................   E-mail ………………………………………………………………………………….......................................   Telephone ……………………………………………………………………………......................................   Post held ……………………………………………………………………………….....................................   Hospital …………………………………………………………………………….....................................…..   Date Basic Course attended ………………………………………………………................................   Preferred topics for discussion  …………………………………………………………………………………………   ………………………………………………………………………………………...........................................…