Application Form for YARE Membership

Personal Details

Title:
First Name*:
Last Name*:
Telephone:
Email*:
Date of Birth*:

Affiliation

Institute*:
City*:
Country*:
Supervisor/Head of group*:
Email supervisor:

* required fields

YARE membership is free of charge. Please note that all personal data are collected for statistical and organizational reasons only. Personal data will be treated as confidential andwill not be passed on to third parties.You hereby agree on receiving information about YARE via email. This agreement can be revoked at any time.Please inform us, if any of your contact information change.The YARE membership automatically ends at the end of the year you turn 36. If you have any questions, do not hesitate to contact .

Date / Signature

Additional information

In order to improve our program and events and for statistical reasons, we would like to ask you some additional questions about your scientific background, your research interests etc. Please double-klick on the fields, to activate them.

  1. Sex

Female

Male

Other

  1. How old are you?

<20 years

20-25 years

25-30 years

>30 years

  1. Where do you come from (nationality)?

Germany

Other, please specify (not mandatory): ______

  1. In which country do you work?

Germany

Other, please specify (not mandatory): ______

  1. What is your track of professional education?

Natural science (biology, chemistry, pharmacy, physics, earth/space sciences…)

Please specify: ______

Medicine

Humanities

Social Sciences

  1. What is your current position?

Student

PhD student

PhD postdoc

MD (medical doctor, physician)

Other, please specify: ______

  1. Where do you work?

Industry

Academic institution (i.e. university, university hospital)

Non-academic hospital

Scientific institution (i.e. foundation)

Other, please specify: ______

  1. What is your general research area?

Basic

Clinical

Translational

  1. What is your field of research?

Adrenal

Bone

Diabetes and Obesity

Endocrine Malignancies

Growth Hormone

Metabolism

Pituitary

Reproduction

Thyroid

Other, please specify: ______

  1. How did you hear about the YARE?

German Endocrine Society (DGE) website

German Endocrine Society Conference

European Society of Endocrinology Conference

ESE Summer School on Endocrinology (Bregenz)

Facebook

Flyer

Friends/ Colleagues

Supervisor

YARE website

Other, please specify: ______

  1. Why do you want to become YARE member?
    ______

______

  1. How many annual YARE meetings have you already attended?

0

1

2

3

4

5

>5

Please send the filled document (as Word file) to .

In addition, please send a signed version as PDF-file/picture to . The signed version can also be sent to:

Dr. Rebecca Oelkrug

Center of Brain, Behavior and Metabolism

AG Mittag – MolecularEndocrinology

Haus 66 – 1. OG Raum 26

RatzeburgerAllee 160

23562 Lübeck