EPF Autumn Regional Advocacy Seminar for Patient Leaders - Registration Form

We have the pleasure to invite you to the European Patients Forum (EPF) Autumn Regional Advocacy Seminar that will take place in Budapest, Hungary on 25-27 October 2010. The seminar is organised in cooperation with the Hungarian Osteoporosis Patient Association (HOPA), Associate Member of EPF.

Due to limited number of places we might not be able to accept all registrations; we will send you confirmation that your registration has been accepted. We will be unable to accept registration from patient organisations that are not in the position to send both a young and older representative unless there are justifiable reasons that EPF will consider acceptable.

Please fill in the registration form below. Deadline of the registration 21st September 2010.

 PERSONAL DETAILS
  
Title
  
Surname *
  
First Name(s) *
  
Job Title
  
Organisation *
  
Organisation postal address
  
Office phone number
  
Office FAX number
  
Mobile phone number
  
Email *
  
Date of Birth *
  
Are you are YOUNG representative? (To be aged between 15-25 years)
  
Are you are SENIOR representative? (Older than 25 year)
  
Please state any special requirements
  
Please specify special requirements
 TRAVEL
 Participants are invited to make their own travel arrangements. Travel expences will be reimbursed by EPF.
 Transfers from/to airport will not be organised. Further information on travel options from the airport will be sent will final papers.
 ACCOMODATION
  
Check in date and time
  
Check out date
  
 The two nights of the 25 - 27 of October are payable by the event organisers. Optional supplementary stay at the hotel venue would be at your own expense.
 If you wish staying additional nights, please provide below details of your credit card to enable us making reservation for you.
  
 CREDIT CARD DETAILS TO GUARANTEE ACCOMODATION
Name of cardholder
Card Type / Number
Card expiry date
 ATTENDANCE
  
Will attend dinner on 25th October *
  
 Should you encounter any problems, please contact event organisers at events2010@eu-patient.eu
 Your registration will be reviewed and confirmed by EPF.