Registration Form SAFE Mentor Training 2013 - PD Karl Heinz Brisch

Klinikum der Universität München · Kinderklinik und Poliklinik im Dr. von Haunerschen
Kinderspital Pettenkoferstr. 10 · 80336 München . Pädiatrische Psychosomatik und
Psychotherapie
Claudia Di Muro
Pediatric Psychosomatic Medicine and
Psychotherapy
Dr. von Hauner Children’s Hospital
Pettenkoferstrasse 8a
80336 Munich/Germany
Ihr Zeichen: Unser Zeichen:
Direktor/-in der Klinik: Prof. Dr. Christoph Klein
Das Klinikum der Universität München ist eine Anstalt des Öffentlichen Rechts
CAMPUS INNENSTADT
DR. VON HAUNERSCHES KINDERSPITAL
KLINIK UND POLIKLINIK
Registration Form
Vorstand: Ärztlicher Direktor: Prof. Dr. Burkhard Göke (Vorsitz), Kaufmännischer Direktor: Gerd Koslowski,
Pflegedirektor: Peter Jacobs, Vertreter der Medizinischen Fakultät: Prof. Dr. Dr. h.c. Maximilian Reiser (Dekan)
Institutionskennzeichen: 260 914 050, Umsatzsteuer-Identifikationsnummer gemäß §27a Umsatzsteuergesetz: DE 813 536 017
OA PD Dr. med. Karl Heinz Brisch
Pädiatrische Psychosomatik
und Psychotherapie
Telefon +49 (0)89 5160 3709
Telefax +49 (0)89 5160 4730
Karl-Heinz.Brisch@med.unimuenchen.de
www.klinikum.uni-muenchen.de
Postanschrift:
Pettenkoferstr. 8A
D-80336 München
München,28.08.2012
SAFE®- SAFE ATTACHMENT FORMATION FOR EDUCATORS
Mentor Training
Module 1 on Monday, 3.6.2013, from 9.30 to 18.00 h
Module 2 on Tuesday, 4.6.2013, from 9.30 to 18.00 h
Module 3 on Wednesday, 5.6.2013, from 9.30 to 18.00 h
Module 4 on Thursday, 6.6.2013, from 9.30 to 17.00h
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Last Name
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First Name
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Street
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Postal code, City, Country
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Phone at work:
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private:
_______________________________________________________________________
Fax
_______________________________________________________________________
Email
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Schooling and Profession
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Special experience
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Trauma therapeutic formation: yes/no

KLINIKUM DER UNIVERSITÄT MÜNCHEN SEITE 2 VON 3
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Training venue: Kolpinghaus, Adolf-Kolping-Str.1, 80336 Munich.
Registration fee for the entire training block: € 520,-
Responsible person for registration: Claudia Di Muro, phone no. +49-89-
5160 3545, email: claudia.muro@med.uni-muenchen.de
Binding Registration:
The SAFE® Mentor Training can only be booked as a complete block, and
the registration fee is due for payment immediately upon registration, by
bank transfer of 520,- Euro.
I am aware that with my signature I register bindingly for the Safe®-
Mentor Training Module 1-4, and that I accept the conditions of
registration.
Please remit the amount to:
Recipient : Klinikum der Universität München
Bank : Bayerische Landesbank München
Account no. : 200 40
Bank code : 700 500 00
Keyword : Finanzstelle: SAFE®: 3.6.13, No.: 7411953
(please indicate exactly as given!)
For remittance abroad:
Swift : BYLADEMM
IBAN-no. : DE 41 7005 0000 0000 0200 40
Registrations will be taken into account according to sequence of receipt of
the money. You will receive the confirmation of receipt of money and the
related registration by e-mail. In case you explicitly would like to receive a
written confirmation by post, please tick here: □
You will receive your RECEIPT after termination of the SAFE® Mentor
Training together with your certificate.
Due to the considerable administrative expense, we can only make out an
invoice on special request. If you need an invoice, please inquire by mail or
phone.
With my signature I register bindingly for the SAFE®- Mentors- Training and I
accept the following participation- and cancellation conditions:
The registration is binding. A handling fee of € 50,- will be charged in case of
cancellation. In case of cancellation on short notice (after the 05.05.13) or
non-attendance, the complete amount will be charged, without any claim for
refund. The number of participants is limited.
The training and the achievement of the goals of the training are greatly based
on mutual reliance. If this base of reliance is not given, then it will not be
possible to reach the goals of the program. In this case the organizer has the
right to exercise his property rights and to exclude the participant from the
program. In this case the whole amount of registration fee will be refunded.

KLINIKUM DER UNIVERSITÄT MÜNCHEN SEITE 3 VON 3
We kindly ask to understand that we must reserve the rights for cancellation of
seminars or changes of programs e.g. low number of participants, drop out of
a lecturer, closure of a hotel or cases of Force Majeure. In case of cancellation
of a seminar because of low number of participants, we will communicate this
at the latest 2 weeks before start of the seminar. At cancellation of a seminar
the registration fee will naturally be refunded entirely. The organizer will not
answer for vain expenditures or other drawbacks which arise from the
cancellation unless in cases of deliberate intention or gross negligence.
I commit myself to adhere to the basic principles and also to the contents of
the manual on the SAFE®- Program and not to deviate from them. Should I not
adhere to the principles or should I deviate from them, the organizer, Dr.
Brisch, has the right to revoke my entitlement to advertise with the term
“SAFE®- Program”, to offer a “SAFE®-course”, or to call myself “SAFE®-
Mentor”.
Place: Date: Signature:
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Name, first name