APPLICATION FORM

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APPLICATION FORM

IPOKRaTES Students

Bedside-teaching Seminar - Symptoms, Signs and Interpretation in Pediatrics

October 8-12, 2018 at Dr. von Haunersches Kinderspital, Munich

Prof. Clifford Lo, MD
Harvard Medical School, Boston, USA

Name *

Address *

E-mail address *

Phone number

University

Semester

Clinical Semester

Please tell us in a few sentences why you would like to participate in our seminar: *

I have completed the following courses (only those relevant for the seminar): *

I learned about this IPOKRaTES seminar through:

Data protection

Not used for advertising: The affiliate agrees that his personal data (name, address, university, contact details) may be used for informing him about the state of his application and may therefore be processed by the IPOKRaTES foundation. For the application process and for storage these data will be passed on to google.

This agreement can be cancelled at any time via e-mail to munich@ipokrates.com.

By disagreeing the lawfulness of the data processing up to this point will not be affected.

I hereby agree

Required

Fee:

The charge for the seminar will not exceed EUR 135,00 for external students and EUR 75,00 for LMU students (board and lodging not included).
The charges will cover the expenses for flights and lodging of the visiting teachers.

IPOKRaTES Students is a non-profit organization!

Selection of participants is subject to IPOKRaTES. Early applications will be favoured. Cancellation at short notice cannot be accepted.

Contact:

If you have any questions please do not hesitate to contact us via email:
munich@ipokrates.com

Next steps:

Having sent us this form, you will receive a confirmation of your application via email.
Regrettably we are unable to guarantee a definite participation due to the limited number of
available spaces. Having assigned the spaces, we will send you a confirmation of
course registration as well as our banking information. Please transfer the course charge as
soon as possible, since we cannot book your place on our workshop prior to this. Please
indicate the reference for your transfer as follows: „IPOKRaTES Students Seminar Pediatrics
Munich YourName“. Unfortunately, we are unable to reimburse course charges in case of
cancellation at short notice. The spaces of our seminar cannot be assigned to other students
without prior consultation with a staff member of IPOKRaTES STUDENTS.
Please do not hesitate to contact us with your questions via email.

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