Women United: A Roundtable on Women in the Union

Please reserve a place for me at the Womens Roundtable event, on Saturday 2nd February 2013. Name: Address: Surname :

Postcode: Telephone: Region Email: __________________________ Yes No Membership No: Division:

Would you like to bring a carer or someone to assist you? (this person will not be charged a conference fee) FIRST NAMED APPLICANT Are you a wheelchair user? Do you require assistance? Y Y N N N

CARER/ASSISTANT Name: Address : Postcod e: Phone:

Do you require an induction loop? Y Dietary requirement: Special requirements?

Dietary requirement: Special requirements?

What is your age? Under 35 35-44

45-55

55+

How would you best describe yourself? NUT member focused on issues in my school NUT school representative NUT member who opens mail (not rep) NUT local lay officer NUT division secretary National Exec member Do you need crche facilities at the event? Do you have children? If yes, please indicate 1 child More than 1 child Do you have grandchildren? How old are your children: I have one or more child under 5 I have one or more children aged 5-18 I have one or more children aged 18+ London Executive Local Associations Members 100 100 FREE Regions (except London) Wales 80 80 FREE Yes Yes No No

Yes

No

Please return to: Jo-Anne Rampling National Union of Teachers Hamilton House Mabledon Place London WC1H 9BD Fax: 020 7387 8458 Email: j.rampling@nut.org.uk Please complete and return this form as soon as possible but not later than Monday 14th January 2013.