First name:
Last name:
Date of birth:	Day:    Month:   Year:
Sex:	Male  Female
Passport number:
Email address:
City:
Street:
Country:

ZIP code:
Phone:
Mobile:

 

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University

 

Medical school

 

Medical student since year

 

EMSA member

Yes
No

Member of any other medical student association

 

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Do you need visa to get to Croatia?

Yes
No

I am from Croatia

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I would like you to organize accomodation for me, at an additional price of 120,00 kn/day (16,00 EUR/day). 

Yes
No

I will arrive by

Car
Bus

Train

Plain

I am from Zagreb

 

Arrival date: 

Please select a date ... October 23rd October 24th October 25th October 26th Other

 

Departure date:

Please select a date ... October 25th October 26th October 27th Other

 

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Do you prefer a specific diet ?

Yes
No

If yes, can you please specify the type of diet ?

 

 

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Details about your scientific paper: 

 

Name of the scientific paper/presentation (up to 10 words, maximum): 

 

 

Authors: 

1. Participation in 2^nd ZIMS:     Yes No

2. Participation in 2^nd ZIMS:     Yes No

3. Participation in 2^nd ZIMS:     Yes No

4. Participation in 2^nd ZIMS:     Yes No

 

Menthors: 

1.

2.

 

University: 

 

Keywords

 

Copy and paste your abstract here: 

 

 

I will present this scientific paper in form of 

Oral presentation
Poster

 

Name of the lecturer (there can be only one)

 

Resources needed for the presentation

Diaprojector with regular slides

Two diaprojectrs

Computor (MS Powerpoint)

Video

     Other:

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Would you like to go to filed trip to Varazdin?

Yes
No

Maybe

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How did you found out about 2^nd ZIMS ?

Internet

Leaflet

Friend

Posters in my faculty office

E-mail

I was participant in ZIMS 2001

     Other:

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Any comments ?