COUNT DOWN

until Friday, June 27 2008

Organized by


Register Application Form

( * ) Please fill out the required field

PERSONAL INFORMATION
Surname
*
Middle name
Given name
*
Name you would like on your name tag
*
Country of citizenship
Passport number
Date of birth
(dd-mm-yyyy)
Spoken languages
Pharmacy school


Gender
CONTACT INFOMATION
Mailing address
 *
E-mail address
*
Home phone number
Mobile phone number
 *
I don't want my personal contact and photo to be published in the symposium folder.
IPSF INFORMATION
Which of the following best describes your involvement/role at the congress?
 INTERNATIONAL Pharmacy Student
DOMESTIC Pharmacy Student
Official Delegate, if so, what organization?
IPSF Executive Member
Individual Member
Regional Officer
Subcommittee Member
Pharmacist
ACCOMMODATIONS
If you have a preferred roommate for two-person occupancy, please fill out their information.
If you do not have a preferred roommate, please leave this section blank.
     Name :
Country :

* All accommodation is in double bed room and same gender in the same room is required

RELEVANT MEDICAL INFORMATION
Do you have any know allergies to food or medication ?
 NO Yes *
- If yes, please specify
Do you have any dietary requirements ?
NO Yes *
- If yes, please specify
Do you have any medical conditions that the RC should be aware of ?
NO Yes *
- If yes, please specify
EMERGENCY CONTACT INFORMATION
In the case of an emergency,
please provide a person whom we should contact on your behalf.
Full name
 *
Relationship
 *
Email address
 *
Home phone number
Mobile phone number
 *
   
REGISTRATION FEES & PAYMENT INFO
Registration fees
Today is in the End Register
End Register
  • Symposium fees are to be paid in US Dollars by wire transfer only.
  • Payment should be paid within 2 weeks after the Application form is submitted. Otherwise, your application will not be processed and become invalid.
  • The symposium fee covers the accommodation, transportation, and meals during the duration of the symposium but NOT the TFT and Post-Symposium Tour.
Post-Symposium Tour info
Post-symposium tour
(July 3rd -July 5th )
 Registration fee: 250 US$
Do you want to attend the 3-day Post-Symposium tour ?
No Yes *
Training for trainer (TFT) info
Training for trainer
(TFT programe Jun 25th -Ju 27th, 2008)
Registration fee: 100 US$
Do you want attend the Training for trainer
(TFT program) ?
No Yes *
If yes, please send your CV along with this form for registration
What is your motivation to participate in TFT?
Have you participated in a TFT workshop before?
 No Yes
What are 3 things that you consider most important for a trainer?


Give 3 words that your best friend will use to describe you


What student organizations or groups have you been involved with?
Bank account details for wire transfer

CANCELLATION
If notification of cancellation is received in writing:

  • Before May 15th, 2008 – The Reception Committee will retain 50% of the paid fees to cover administration.
  • After May 15th, 2008 – The Reception Committee will retain 100% of the paid fees with no refund made to the participant.