NIP Speaker Form NIP Speaker Form Step 1 of 3 33% Nursing in Practice 2024 Speaker RegistrationEvent Selection-Please Select-Nursing in Practice Live London - 28 March 2024Nursing in Practice Live Southampton - 23 May 2024Nursing in Practice Live Liverpool - 13 November 2024Nursing in Practice Live Belfast - 6 November 2024Nursing in Practice Live Cardiff - 19 September 2024Event Information Date: - 28 March 2024 Location: London - Novotel London West Date: 23 May 2024 Location: Southampton - Leonardo Grand Harbour Date: 13 th November 2024 Location: Liverpool - ACC Date: 6 November 2024 Location: Belfast - Crowne Plaza Date: 19th September 2024 Location: Cardiff - All Nations Your DetailsName(Required) -Please Select-DrMissMrMrsMsProf Title Forename Surname Email(Required) Enter Email Confirm Email Which job title most closely matches your job role:(Required)-Please Select-Practice NurseCommunity NurseDistrict NurseNurse PractitionerSchool NurseSenior Nurse/Team LeaderRegistered Mental Health Nurse (RMN)Health VisitorOther, Please SpecifyOther Job Role(Required) HiddenNMC Pin Work Phone NumberMobile Phone Number(Required)Work AddressPractice Name/ Place of Work:(Required) Address(Required) Street Address City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HiddenHow did you hear about us?-Please Select-Media partner (for example, Education for Health, or SPNA)EmailFacebook advertFacebook postFriend/ColleagueGoogle AdvertLinkedInNewspaper StoryNursing in Practice E-NewsletterNursing in Practice MagazineOnline AdvertReceived something in the postTelemarketingTwitter advertTwitter postWeb SearchHiddenAre you a prescriber? Yes No HiddenPlease select which topics you are most interested in (tick at least one) Wound Care Mental Health Diabetes Cardiovascular disease Women's Health Sexual Health Cancer & pallative care Resipiratory Public Health Obesity and Nutrition Dermatology MSK & Pain Vaccinations GDPR/DATA PROTECTIONBy allowing my badge to be scanned by a sponsor company in the exhibition hall or at sponsored sessions, I am agreeing for the event organisers to pass on my details provided to this company and for this third party to contact me after the event about their products, events and/or services - some of which may be promotional in nature. I have the right to contact them to have my data removed or to not have my badge scanned. The personal data provided in this form will be processed in accordance with UK law by Cogora Group Ltd. In addition to the purposes described above, we may process your information for carefully considered and specific purposes to enhance the services we provide. You have the right to object to this processing if you wish. For further details on how Cogora Ltd may process your information and your rights in relation to the information we hold on you, please visit our privacy policy or telephone us on 020 7214 0500. Please note that your name, phone number and email address may be passed onto third parties including, but not limited to, the venue, public health authorities and NHS, for the purposes of contact tracing purposes.Cogora Limited Registered in England No. 02147432 Registered Address: 1 Giltspur St, London EC1A 9DDSpeaker DeclarationBy signing, I agree that I am aware that there may be journalists present at the event from Cogora, the organiser of the events, and external media and that details of my seminar/workshop may be reported. Cogora may also record the session and share my presentation with delegates and other relevant members of the healthcare community. I consent for video footage of me/my session to be shared with delegates and relevant healthcare professionals online by Cogora.(Required) Yes No I consent for photographs of me/my session to be used for marketing and PR purposes by Cogora.(Required) Yes No I consent for my presentation to be shared with delegates and relevant healthcare professionals after the event.(Required) Yes No Sign (type your name)(Required) HiddenAdmin- Please enter the Event/Issue ID's into the relevant box. - Please enter the marketing reference.HiddenMarketing Reference