RSVP 4 — Aid Via Action

Course Presenter Registration

Name

First Name

Last Name

Email:

Phone:

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###

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Official Title:

Speciality:

Hospital Affiliation:

Address of Hospital Affiliation:

Please provide the name of your talk:

Please provide an abstract about your talk (250 words):

Fee Paid:

Pay with the "Donate" button on the top right of the website. 200 GTQ = $25.94 USD

Yes

No