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 100,00 kn/day (14,00 €/day). 

Yes
No

I will arrive by

Car
Bus

Train

Plain

I am from Zagreb

Arrival date: 

Please select a date ... November 4th November 5th November 6th November 7th November 8th Other

Departure date:

Please select a date ... November 7th November 8th November 9th November 10th 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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If you are not active participant please leave this section blank!

 

Details about your scientific paper:

 

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

 

Authors: 

1. Participation in 3^rd ZIMS:     Yes No

2. Participation in 3^rd ZIMS:     Yes No

3. Participation in 3^rd ZIMS:     Yes No

4. Participation in 3^rd 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

I have portable computer

     Other:

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Would you like to go to filed trip to Samobor?

Yes
No

Maybe

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How did you found out about 3^rd ZIMS ?

Internet

Leaflet

Friend

Posters in my faculty office

E-mail

I was participant in 1^st or 2^nd ZIMS

     Other:

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Any comments ?