Advances in Otology and Related Sciences &

5th Portmann Course on Advanced Otological Surgery

5th Portmann Course on Advanced Otological Surgery: 12 ~ 15 October 2010

Prince of Wales Hospital & Alice Ho Miu Ling Nethersole Hospital, Hong Kong

Main Conference: 16 ~ 17 October 2010

Prince of Wales Hospital, Hong Kong

REGISTRARION FORM

Registration Method

(1) Complete this registration form in BLOCK LETTERS and return with the appropriate registration fee to the Secretariat; OR

(2) Register online at our website www.ent.cuhk.edu.hk/advanceconf2010

Participant’s Information
Salutation: / o Professor o Doctor o Mr. o Ms.
Surname: / Given Name:
Position: / Department:
Institution:
Mailing Address:
Country:
Tel: / Fax:
Email:

o I am a member of the Hong Kong College of Otorhinolaryngologists / Hong Kong Society of Otorhinolaryngology, Head and Neck Surgery. (delete as appropriate)

o I am not a member of the above College / Society. (delete as appropriate)

Registration fee entitles you to the main scientific and registered programme, programme materials, coffee breaks and lunch, congress dinner and promotional gifts (distributed on a first-come-first-served basis).

Conference Secretariat:

Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong

6/F, Clinical Sciences Building, Prince of Wales Hospital, Shatin, Hong Kong

Tel No. : (852) 2947 8284

Fax No. : (852) 2145 8876

Email :

Website : www.ent.cuhk.edu.hk/advanceconf2010


Registration Fee

Main Conference on Advances in Otology and Related Sciences
5th Portmann Course on Advanced Otological Surgery
Audiology Workshop on Advanced Audiological Assessments for Better Rehabilitation
Speech Therapy Workshop on Habilitation of Children with Hearing-impairment and Additional Needs
Main Conference * / Portmann Course
(Live Surgery + Lecture) / Portmann Course
(Live Surgery +
Lecture + Dissection) / Audiology Workshop / Speech Therapy Workshop
On or before
23 Aug 2010 / After
23 Aug 2010
ENT Specialist / HK$ 2,000 / HK$ 2,500 / HK$ 6,500 / / HK$ 500 / HK$ 1,900
(before 1 Sept)
HK$ 2,500
(after 1 Sept)
Trainee # / HK$ 1,500 / HK$ 2,500
Audiologist/ Nurse/
Speech Therapist / HK$ 300
(Conference dinner excluded) / HK$ 300 / N.A.
Conference Dinner for
Audiologist/Nurse/
Speech Therapist/
Accompanying Person / HK$ 600
(Conference dinner included) / HK$ 600 / HK$ 600 / HK$ 600 / HK$ 600
Grand Total : HK$______

Remarks:

* 10% discount off the regular registration fee of Main Conference will be offered to:

1. / Fellows and doctors of the Hong Kong College of Otorhinolaryngologists
2. / Regular and associate members of the Hong Kong Society of Otorhinolaryngology, Head & Neck Surgery

# Proof required.

Payment Method

o Credit Card Payment / o Visa o MasterCard
Cardholder’s Name
Surname / Given Name
Card Number
Expiry Date / Amount HK$
(mm/yyyy)
Signature of Cardholder

o A bank draft for HK$ ______payable to "The Chinese University of Hong Kong."

o Personal cheque for the amount of HK$ ______made payable to "The Chinese University of Hong Kong." (For Hong Kong residents only)

Signature of Applicant / Date

Should the programme scheduled have to be cancelled due to the Rainstorm Black Warning or the hoisting of typhoon signal No. 8 or above or other unforeseeable circumstances, the organizer shall try to re-schedule the programme whenever possible. No registration fees shall be re-funded to delegates after confirmation of registration.

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