Registration Form

Instructions

This form is intended to register you for the 2017 Young Medicial Professionals Conference in SUMY, UKRAINEĀ . The conference will be conducted October 20th, 21th and 22th. There is a fee associated with attending the conference. You will need to contact the local registration cordinator to make payment.

When the form is submitted you need to notify the coordinator for your local city. This coordinator needs to be contacted in order to make payment of your registration a fee for the conference. If you are traveling internationally the ICMA Team will act as your coordinatorinternationally the ICMA Team will act as your coordinator.
Please select a year. If you have already completed your education please choose the year, or if the year is prior to 2010 - Please select 2010.

Form Notices

We are asking you to check the box below to acknowledge that you understand if you have questions about the conference, feedback or other concerns they need to be submitted via the Contact Us page of the website and not through this form.
We are asking you to check the box below to acknowledge that you understand question about the conference, feedback or other concerns need to be submitted contact us page of the website and not through this form.
During the conference there will be someone taking pictures for promotion of future events. Some of the pictures will be used to help others see the impact and the effectiveness of this conference. We want to let you know that pictures are part of the event. Check the box to acknowledge - "I understand my picture may be taken during the conference and give my permission to use my photograph in future published material or online promotion."
I understand after the conference my contact information will be shared with Christian Medical organizations in my home country to offer the possibility of participating in a mentoring program.

Participant Details

Please enter your full name and title as required.
Enter the email address where we can contact you immediately.
Please provide a telephone number so the coordinator of registration can contact you if needed.
if for some reason the phone number does not work with the above input or you have a second phone number, please include that here.
We need the name of your university or institution to coordinate additional details.
Please provide the city of your university or institution.
Please enter your date of birth. (dd/mm/yyyy)
Please enter your nationality.
Do you need a VISA to attend the conference?
(Please only provide this if you need a VISA.)
Please specify the country where the passport was issued. This is only needed if you require a VISA.
(Please specify the date your passport will expire. This is only required if you need a VISA. Format: dd/mm/yyyy)

Introduction

Are you a vegetarian?
Please help us get to know you. Please tell us a little bit about yourself. (20 word min and 200 words max)

Accommodation

Please indicate your choice of roommate or roommates by listing their name or names below. Every effort will be made to match you with this person or persons. You may add no more than 3 choices of roommates.

Travel

Enter Date of Arrival (dd/mm/yyyy)
Enter time of arrival. (format: 00:00:00, Example 01:00:00 = 1am 13:00:00 = 1pm)
Enter departure date (dd/mm/yyyy)
Select departure time. (format: 00:00:00, Example 01:00:00 = 1am 13:00:00 = 1pm)

Please verify you have answered all the questions. Please make sure you have checked the two boxes at the top of the form.

Any specific details we need to know about contacting you?