2011 Reg Form Eng (DOC)

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2011 Reg Form Eng (DOC) Powered By Docstoc
					                                  Advances in Facial Plastic Surgery and Rhinology
                                     and Pre-conference Cadaveric Workshops
                                       Prince of Wales Hospital, Hong Kong
                                                     Registration Form
(1) Complete this registration form in BLOCK LETTERS and return with the appropriate registration fee to the Secretariat; OR
(2) Register online at our website www.ent.cuhk.edu.hk/entconf2011
  Salutation:                Professor          Doctor          Mr.            Ms.
  Surname:                                                         Given Name:
  Position:                                                    Department:
                             Facial Plastic  Rhinology/Skull Base  Plastic, Reconstructive and Aesthetic Surgery
  Subspecialty               Oral and Maxillofacial Surgery          Others_____________________________
  Mailing Address:
  Tel:                                                            Fax:
 I am a member of the Pan Asia Academy of Facial Plastic & Reconstructive Surgery / American Academy of Facial &
    Plastic Reconstructive Surgery / European Academy of Facial Plastic Surgery / Brazilian Academy of Facial Plastic
    Surgery / Mexican Society of Rhinology & Facial Plastic Surgery / Australasian Academy of Facial Plastic Surgery.
    (delete as appropriate)

 I am a delegate from Asia / Australasia region.
    I am most interested in the  Facial Plastic Programme     Rhinology/Skull Base Programme (please tick one for our
    conference logistic arrangement.)

 Registration Category
  Main Conference
                                                                                 On or before 30 Nov       On or after 1 Dec
   Advances in Facial Plastic Surgery and Rhinology (7-9                                HK$1,500             HK$2,000
    Dec 2011)
  Pre-conference Cadaveric Workshop
   Rhinoplasty Dissection Course (5 Dec 2011)             FULL !                            HK$8,500       FULL !
   Rhinoplasty Dissection Course (5 Dec 2011) Lecture Only FULL !                           HK$800         FULL !
   Advanced Endoscopic Skull Base Surgery (6 Dec 2011) FULL !                               HK$12,000      FULL !
                                                     Grand Total HK$

  Payment Method
   Credit Card Payment           Visa       MasterCard     Card Issuing Bank

     Cardholder’s Name           Surname                                  Given Name

     Card Number

     Expiry Date                 (mm/yyyy)                                    Amount HK$

     Signature of Cardholder

   A bank draft for HK$______________ payable to "The Chinese University of Hong Kong".
   Personal cheque for the amount of HK$ ________________ made payable to "The Chinese University of Hong Kong". (For
    Hong Kong residents only)

                   Signature of Applicant                                                           Date
Remarks to Participants of Rhinoplasty Workshop:
    Instruments will be provided but course delegates are welcome to bring their own instruments. Please kindly
     inform the secretariat if you wish to do so for inventory purposes.
    Two participants will share one cadaver head.
    All participants will agree to follow Professor Palma’s step-by-step command so as to fully understand the
     rhinoplasty dissection. Participants are to perform each step as group without deviation.
    Local faculty will be present to supervise dissection tables.
    Limited places granted on a first-come-first-served basis to the following specialty surgeons with an interest in
                               ENT and Facial Plastic Surgeon
                               Plastic, Reconstructive and Aesthetic Surgeon


                                                             5 Dec                5 Dec
                                                                                               6 Dec     7 Dec         8 Dec         9 Dec
                                                       (Hands-on + lecture)   (lecture only)
      Hong Kong College of Otorhinolaryngologists            7 (cat 14)         4 (cat 2)       8      7 (cat 2) *   7 (cat 2) *   7 (cat 2) *

      Hong Kong College of Surgeons                         6 (passive)         Pending

     * Maximum of 20 points can be granted for 3-day conference.

 Payment, Cancellation and Refund Policy:
    Should the programme scheduled have to be cancelled due to unforeseeable circumstances, the organizer shall try
     to re-schedule the programme whenever possible. There will be no refund if the delegate cannot attend the re-
     scheduled programme. If, for reasons beyond the control of the Organizing Committee, the 2011 CUHK ENT
     Conference, and/or its pre-conference workshops are cancelled, registration fees will be refunded after the
     deduction of conference expenses already incurred.

 Conference Secretariat:
 Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong
 6/F, Clinical Sciences Building, Prince of Wales Hospital, Shatin, Hong Kong

 Tel No.    :    (852) 2632 1277
 Fax No.    :    (852) 2145 8876
 Email      :    entconf@ent.cuhk.edu.hk
 Website    :    www.ent.cuhk.edu.hk/entconf2011

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