EPNS Masterclass 2024 Registration form for One Person

COMPLETE THIS FORM to register for ONE person to attend the EPNS Masterclass with accommodation included (450 Euros) OR with no accommodation included (350 Euros).
Delegates are encouraged to register as a “couples”; a senior mentoring clinician and a mentee/leader of tomorrow. Couples do not necessarily have to work at the same hospital but must have a mentor/mentee connection.

You are completing this form as an individual with no partner, and you are most welcome to do so. We will strive to find another delegate to become your partner.
If instead you would like to register as a “couple”, please select the form entitled 'EPNS Masterclass 2024 Registration form for Two People (785 Euros or 600 Euros with NO accommodation)'

All fields marked (*) are mandatory.

To help in the organisation, please select one of the following: (*)

---I am a senior mentoring clinician.I am a young leader of tomorrow (suggested under 45 years old, with a clinical practice in paediatric neurology and active in research and teaching).

Title (*)
---Ass ProfDozDrProfProf DrMsMr

First name (*)

Last name (*)

Email (*)

Mobile Telephone Number (*)

Work Address (*)

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 time approximately will you arrive on Wed 18 September 2024 (the masterclass begins first thing on Thurs 19 Sept 2024)? Please tick the appropriate box (*)
---morningmiddayafternooneveningOther (please state below)
If other ...

Will you be attending the optional social event on Thursday 19 September 2024 for an extra cost of 60 Euros per person? (Kettles Yard and dinner at the Eagle pub)? Note: drinks at The Eagle are NOT included in this price. Guests need to purchase their own drinks from the bar (*)
---yesno

Will you be attending the conference dinner on Friday 20 September 2024 at Corpus Christi (this is included in the registration fee)? (*)
---yesno

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 ...

I am an EPNS member and I have paid my 2024 EPNS Membership fee (MANDATORY. Will be verified) (*)

I would like pay the following registration fee: (*)
---Registration fee including accommodation = 450 EurosRegistration fee with NO accommodation = 350 Euros

I understand the registration fee of 450 Euros includes accommodation for 3 nights (18,19,20 September 2024) at either at Corpus Christi, St Catharine’s College or Gonville and Caius College in an en-suite single room and that these are student rooms and can be quite basic (This field is mandatory therefore, please tick even if not registering for accommodation to be included)(*)

I will need accommodation for additional nights (cost 100 Euros per night) (*)
---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 websitebank transfer

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

I understand to confirm this reservation, I must pay the registration fee (plus fee for extra nights accommodation and Thursday social evening event if applicable).(*)

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