Biennial EPNS Caucasus Teaching Course 18 – 19 November 2022 REGISTRATION FORM FOR IN-PERSON ATTENDANCE

EPNS Statement: The EPNS expresses deepest solidarity with the Ukrainian people. During this time of conflict, as an academic medical Society focused on ​amelioration of neurological care for children and their families, research and education, the EPNS welcomes all nations with respect in the international exchange of science. Ukrainian colleagues are invited to register for the EPNS Caucasus course 2022 for free. To learn how to register for free, Ukrainian colleagues can email info@epns.info for more information.

You are completing this form to attend the EPNS Caucasus Teaching Course 2022 IN-PERSON in Tbilisi, Georgia.

If instead you would like to register to attend virtually, please visit https://www.winglet-community.com/5th-biennial-epns-hybrid-caucasus-teaching-course or contact cd@winglet-education.com

All fields marked (*) are mandatory.

Title (*)
---Ass ProfDozDrProfProf DrMsMr

First name (*)

Last name (*)

Email (*)

Are you a student interested in paediatric neurology? (*)
---yes (if yes, proof that you are a student must be shown on arrival at the training course venueno

City (*)

Zip Code (*)

Country (*)
---AFGHANISTANÅLAND ISLANDSALBANIAALGERIAAMERICAN SAMOAANDORRAANGOLAANGUILLAANTARCTICAANTIGUA AND BARBUDAARGENTINAARMENIAARUBAAUSTRALIAAUSTRIAAZERBAIJANBAHAMASBAHRAINBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBENINBERMUDABHUTANBOLIVIABOSNIA AND HERZEGOVINABOTSWANABOUVET ISLANDBRAZILBRITISH INDIAN OCEAN TERRITORYBRUNEI DARUSSALAMBULGARIABURKINA FASOBURUNDICAMBODIACAMEROONCANADACAPE VERDECAYMAN ISLANDSCENTRAL AFRICAN REPUBLICCHADCHILECHINACHRISTMAS ISLANDCOCOS (KEELING) ISLANDSCOLOMBIACOMOROSCONGOCONGOTHE DEMOCRATIC REPUBLIC OF THECOOK ISLANDSCOSTA RICAIVORY COASTCROATIACUBACYPRUSCZECH REPUBLICDENMARKDJIBOUTIDOMINICADOMINICAN REPUBLICECUADOREGYPTEL SALVADOREQUATORIAL GUINEAERITREAESTONIAETHIOPIAFALKLAND ISLANDS (MALVINAS)FAROE ISLANDSFIJIFINLANDFRANCEFRENCH GUIANAFRENCH POLYNESIAFRENCH SOUTHERN TERRITORIESGABONGAMBIAGEORGIAGERMANYGHANAGIBRALTARGREECEGREENLANDGRENADAGUADELOUPEGUAMGUATEMALAGUERNSEYGUINEAGUINEA-BISSAUGUYANAHAITIHEARD ISLAND AND MCDONALD ISLANDSHOLY SEE (VATICAN CITY STATE)HONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRANIRAQIRELANDISLE OF MANISRAELITALYJAMAICAJAPANJERSEYJORDANKAZAKHSTANKENYAKIRIBATIKOREA-DEMOCRATIC PEOPLES REPUBLIC OFKOREA-REPUBLIC OFKUWAITKYRGYZSTANLAO PEOPLES DEMOCRATIC REPUBLICLATVIALEBANONLESOTHOLIBERIALIBYAN ARAB JAMAHIRIYALIECHTENSTEINLITHUANIALUXEMBOURGMACAOMACEDONIA-THE FORMER YUGOSLAV REPUBLIC OFMADAGASCARMALAWIMALAYSIAMALDIVESMALIMALTAMARSHALL ISLANDSMARTINIQUEMAURITANIAMAURITIUSMAYOTTEMEXICOMICRONESIA-FEDERATED STATES OFMOLDOVA-REPUBLIC OFMONACOMONGOLIAMONTENEGROMONTSERRATMOROCCOMOZAMBIQUEMYANMARNAMIBIANAURUNEPALNETHERLANDSNETHERLANDS ANTILLESNEW CALEDONIANEW ZEALANDNICARAGUANIGERNIGERIANIUENORFOLK ISLANDNORTHERN MARIANA ISLANDSNORWAYOMANPAKISTANPALAUPALESTINIAN TERRITORY-OCCUPIEDPANAMAPAPUA NEW GUINEAPARAGUAYPERUPHILIPPINESPITCAIRNPOLANDPORTUGALPUERTO RICOQATARREUNIONROMANIARUSSIAN FEDERATIONRWANDASAINT BARTHÉLEMYSAINT HELENASAINT KITTS AND NEVISSAINT LUCIASAINT MARTINSAINT PIERRE AND MIQUELONSAINT VINCENT AND THE GRENADINESSAMOASAN MARINOSAO TOME AND PRINCIPESAUDI ARABIASENEGALSERBIASEYCHELLESSIERRA LEONESINGAPORESLOVAK REPUBLICSLOVENIASOLOMON ISLANDSSOMALIASOUTH AFRICASOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDSSPAINSRI LANKASUDANSURINAMESVALBARD AND JAN MAYENSWAZILANDSWEDENSWITZERLANDSYRIAN ARAB REPUBLICTAIWAN-PROVINCE OF CHINATAJIKISTANTANZANIA-UNITED REPUBLIC OFTHAILANDTIMOR-LESTETOGOTOKELAUTONGATRINIDAD AND TOBAGOTUNISIATURKEYTURKMENISTANTURKS AND CAICOS ISLANDSTUVALUUGANDAUKRAINEUNITED ARAB EMIRATESUNITED KINGDOMUNITED STATESUNITED STATES MINOR OUTLYING ISLANDSURUGUAYUZBEKISTANVANUATUVENEZUELAVIET NAMVIRGIN ISLANDS-BRITISHVIRGIN ISLANDS-U.S.WALLIS AND FUTUNAWESTERN SAHARAYEMENZAMBIAZIMBABWE

What day and time will you arrive in Tbilsi?

What day and time will you leave Tbilsi?

Do you have any special dietary requirements? (*)
---yesno
If yes, please give details ...

Do you have any special needs (e.g. wheelchair, etc.)? (*)
---yesno
If yes, please give details ...

How will you be paying? Payment details will be sent in the automatic acknowledgement email.(*)
---debit/credit card via EPNS website (only available to EPNS members)bank transfer

I have read, understood and accept EPNS Caucasus Terms and Conditions (*) [+]

I have read, understood and accept EPNS Code of Conduct (*) [+]

I understand to confirm this reservation, I must pay the registration fee. Payment methods details will be sent after the online registration form has been submitted.(*)

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