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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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 ?