APPLICATION FORM
IPOKRaTES Students
Bedside-teaching Seminar - Symptoms, Signs and Interpretation in Pediatrics
February 26 to March 3, 2017 at Klinik und Poliklinik für Kinder- und Jugendmedizin Universitätsklinikum, Leipzig

Prof. John Graef, MD
Children's Hospital, Harvard Medical School, Boston, USA
&
Prof. Clifford Lo, MD
Children's Hospital, Harvard Medical School, Boston, USA

Name *
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Address *
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E-mail address *
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Phone number
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University
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Semester
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Clinical Semester
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Please tell us in a few sentences why you would like to participate in our seminar: *
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I have completed the following courses (only those relevant for the seminar): *
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I learned about this IPOKRaTES seminar through:
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Fee:
The charge for the seminar will not exceed EUR 135,00 (board and lodging not included).
The charges will cover the expenses for flights and lodging of the visiting teachers.

IPOKRaTES Students is a non-profit organization!


Selection of participants is subject to IPOKRaTES. Early applications will be favoured. Cancellation at short notice cannot be accepted.

Contact:
If you have any questions please do not hesitate to contact us via email:
vanessa.vogelsang@ipokrates.com
Next steps:
Having sent us this form, you will receive a confirmation of your application via email.
Regrettably we are unable to guarantee a definite participation due to the limited number of
available spaces (up to 20). Having assigned the spaces, we will send you a confirmation of
course registration as well as our banking information. Please transfer the course charge as
soon as possible, since we cannot book your place on our workshop prior to this. Please
indicate the reference for your transfer as follows: „IPOKRaTES Students Seminar Pediatrics
Leipzig YourName“. Unfortunately, we are unable to reimburse course charges in case of
cancellation at short notice. The spaces of our seminar cannot be assigned to other students
without prior consultation with a staff member of IPOKRaTES STUDENTS.
Please do not hesitate to contact us with your questions via email.
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