Formulir Pendaftaran Peserta Simposium dan Workshop PKB Departemen IKA FKUI-RSCM (LXXVI) Jakarta, 13-15 April 2019

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SELURUH PESERTA WAJIB MENGISI ALAMAT EMAIL PESERTA (BUKAN ALAMAT EMAIL SPONSOR)

Nama lengkap beserta Gelar *

Spesialisasi *

Spesialis Anak / Spesialis Lain

Dokter Umum

PPDS (IKA FKUI - RSCM)

Mahasiswa Kedokteran

Domisili Kota Tinggal *

No. Telepon Selular *

Kegiatan yang akan diikuti *

Simposium

Workshop

Simposium dan Workshop

Topik Workshop (pilih salah satu topik yang diminati bagi seluruh peserta workshop)

Fluid resuscitation and non-invasive monitoring in Dengue Shock Syndrome

Management of pediatric Acute Kidney Injury

Point of care ultrasound: extended focused assessment with sonography in neonatal and pediatric emergency

Basic ventilator therapy of the new born

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Akomodasi (diisi apabila berminat melakukan pemesanan)

Harga akomodasi tipe kamar "Grand room" Rp. 1.900.000,- NET/kamar/malam (termasuk makan pagi untuk 2 orang, tambahan makan pagi langsung dibayarkan ke pihak hotel. Pelunasan akomodasi paling lambat tanggal 6 April 2019

1 Malam

2 Malam

3 Malam

4 Malam

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Tipe Bed

Twin

Single/King

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Tanggal "check in" dan "check out"

Status Pembayaran *

Apabila peserta di daftarkan oleh sponsor, mohon lengkapi data isian sponsor.

Pribadi

Sponsor

Voucher PKB IKA (Bila memiliki voucher yang masih berlaku)

Data Sponsor

Nama Perusahaan / Contact Person / No. Telepon Selular / Email (contoh isian : PT. Sejahtera Sentosa / Budi/ 081310002000 / budisetiawanxx@yahoo.com)

Cara Pembayaran

Tunai

Transfer

FOC (Undangan)

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Komentar / Keterangan

Submit

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