REGISTRATION FORM ICF Workshop 3-4 th December Kochin , INDIA Name _______________________________ Position _______________________ Institution/Department _______________________________________________ Address ___________________________________________________________ Postal Code/City ________________________ Country _____________________ Tel. ___________________________ Email ______________________________ Please indicate one or more: I am a(n)... Practitioner/Direct service provider Researcher Teacher/Instructor Student. Which level (doctoral, masters, etc…)? __________________ Administrator Policy-maker Other:________________________ _____________________________ and the level of my ICF knowledge is (possible to check more than one): No knowledge at all Basic / know the ICF model of ICF Can code using ICF including qualifiers Familiar with linking methodology Use the ICF in daily practice/my work My objectives for participating in the ICF Workshop are: _________________________ ___________________________________________________________________________ ___________________________________________________________________________ Participation I would like to participate in the ICF Workshop. No accommodations required. I would like to participate in the ICF Workshop. Kindly reserve a room (single occupancy) for me with check-in on ___________ and check-out on ___________.* Unfortunately, I am unable to participate in this workshop, but would like to be invited to the next workshop held. If payment is not received by 21st nov,2013 we reserve the right to cancel your workshop registration. NOTE: visa is required to enter india, please send us the visa confirmation no . Kindly indicate below if you need an invitation letter for the visa application. Comments:___________________________________________________________________ ____________________________________________________________________________ REGISTRATION FEES The workshop fee ( with breakfast, lunch, coffee breaks and all workshop material) is approx. Rs 10,000 for professionals in Asia and Africa ( only 15 seats available) ,For students all over the globe the cost is INR 5000( only 5 seats available), for delegates outside Asia/Africa the cost is 400 USD(only 10 seats available), workshops are strictly- first come ,first serve basis and since seats are few please reserve them to avoid hassles Mode of Payment 1. Delegates from India-For bank drafts, the DD be drawn in favour of RPSM Research for Disabled Children Trust payable at Lucknow. Postal Address : R. P. Shah Memorial Trust For Children With Disabilities 204, Diamond Tower, Udayganj, Lucknow. Email: dr.vipulshah@yahoo,vipulshak@rediffmail 2. By Wire Transfer International and national delegates Name of Bank: HDFC Name of Account: RPSM Research for Disabled Children Trust Branch: Hazratganj branch, Lucknow Branch code: 0078 Account Number: 00782000024202 SWIFT CODE: HDFC INBB A copy of bank transfer be attached with registration form Conference venue Courtyard Kochi Airport Block No. 9 in Akaparambu Kara in Nedumbassery Village • Kochi, Kerala, 683572 India For stay kindly contact the hotel directly Web page marriott/hotels/travel/cokap-courtyard-kochi-airport Kindly return this form completed to Dr Vipul Shah, Medical Director RP SHAH MEMORIAL TRUST FOR CHILDREN WITH DISABILITY 204 diamond tower udayganj lucknow 226001,India or e mail us on dr.vipulshah@yahoo at the latest by 21st nov 2013. Should you have further questions, please feel free to contact us ( tel-091-9305542233)
Posted on: Fri, 04 Oct 2013 05:07:32 +0000
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