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REGISTRATION FORM FOR MOLECULAR IMAGING SUMMER SCHOOL

Please Register before the 31st of May 2005

  1. Please provide the following contact information:
    First Name
    Last Name
    Organization
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Phone
    FAX
    E-mail
    URL
    (for accommodation
    purposes)

     

  2. Are you member of consortium ...?:


    For information on scholarships click here
    Molecular Imaging participants click here
    EMIL participants click here
    DiMI participants click here

    Accommodation Fees [click here for more information]
    - In a single room , per person per day: 105 Euro
    -     In a double room , per person per day: 80 Euro

  3. If yes, which partner (include Acronym AND Partner number)?


  4. Expected Date of Arrival :

    [dd/mm/yy]

  5. Expected Date of Departure:

    [dd/mm/yy]

  6. Are you a Student / Post-doc?

    Yes No

  7. If yes, you wish to share your room with (leave blank if no preference)


  8. Would you be willing to participate in an extra mini-workshop on (optional):

    Numerical Methods in Molecular Imaging
    Novel In-vivo Imaging Approaches
    New Advances in Molecular Imaging Applications
    None, I prefer to have more free time for discussions

  9. If yes, would you be willing to give a 15min. talk?

    Yes No

  10. Is there an additional mini-workshop you think should be included in the list above?

  11. Please include here any additional comments, suggestions or special needs:

 

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Last modified: 04/19/05