Registration form November 16 2024

"Caring for people at the edges of our healthcare system"

Please register here for our November 16 symposium.
(Your registration for the November 15 programme is on sensiplan.be)

E-mail address *

FIRST NAME of the participant *

FAMILY NAME of the participant *

Full address *

Country *

Please indicate your category *

100 euro (medical doctor)

60 (other profession)

30 euro if < 35 years old (young medical doctor or student)

early bird registration (before 30 June) - 75 euro (medical doctor)

early bird registration (before 30 June) - 45 euro (other profession)

early bird registration (before 30 June) - 15 euro if < 35 years old

0 euro (member of Belgian Medical Association Saint-Luke, therefore free of charge)

Would you like to register a second participant?

Yes

FIRST NAME of the second participant *

FAMILY NAME of the second participant *

Please indicate the category of the second participant *

100 euro (medical doctor)

60 (other profession)

30 euro if < 35 years old (young medical doctor or student)

early bird registration (before 30 June) - 75 euro (medical doctor)

early bird registration (before 30 June) - 45 euro (other profession)

early bird registration (before 30 June) - 15 euro if < 35 years old

0 euro (member of Belgian Medical Association Saint-Luke, therefore free of charge)

Would you like to register a third participant?

Yes

FIRST NAME of the third participant *

FAMILY NAME of the third participant *

Please indicate the category of the third participant *

100 euro (medical doctor)

60 (other profession)

30 euro if < 35 years old (young medical doctor or student)

early bird registration (before 30 June) - 75 euro (medical doctor)

early bird registration (before 30 June) - 45 euro (other profession)

early bird registration (before 30 June) - 15 euro if < 35 years old

0 euro (member of Belgian Medical Association Saint-Luke, therefore free of charge)

Would you like to register a fourth participant?

Yes

FIRST NAME of the fourth participant *

FAMILY NAME of the fourth participant *

Please indicate the category of the fourth participant *

100 euro (medical doctor)

60 (other profession)

30 euro if < 35 years old (young medical doctor or student)

early bird registration (before 30 June) - 75 euro (medical doctor)

early bird registration (before 30 June) - 45 euro (other profession)

early bird registration (before 30 June) - 15 euro if < 35 years old

0 euro (member of Belgian Medical Association Saint-Luke, therefore free of charge)

What is the total amount of your payment? *

Payment instructions please make your payment via bank transfer : BE22 4376 1125 6147 (Belgian Medical Association Saint-Luke) mentioning "your name - nov 16 Leuven" *

I register for the Saturday November 16 symposium, (and will arrange bank transfer within 10 days if applicable).

I would also like to register for the Friday November 15 programme, and I understand I have to contact sensiplan.be myself (seperate registration and payment required!)

Do you have any other comment? (or mail to president@cathmed.be)

Young doctors and students from outside Belgium, can apply for basic accommodation (if <35 years old).

not needed

yes, I apply for free basic accommodation (and breakfast), and would like more information by email. (3 nights)

Registration St-Luke Symposium 16-nov-2024 Leuven