Faculty Member Registration Form

Before filling in the form please read carefully registration terms and conditions (https://www.wacem2024.org/registration - Privacy Policy - Cookie Policy)

Title

Name

First name, given name

Middle name initial(s)

Surname, family name

Layout

Nationality

Date of birth

m/d/Y

Email address

Mobile phone number

Select your country code

Credentials

As you would like to appear in the Congress website - Medical Profession, Company/Institution, Department, City/Town, State/Country (e.g. Emergency Medicine Doctor, Sapienza University of Rome, Department of Emergency Medicine, Rome, Italy)

Home Address

Address Line 1

Address (2)

Address Line 2

Layout

City

State (if relevant)

Postal Code

Country

Special meals requirements (if any)

(e.g.: vegetarian, no pork, no beef, no fish …)

YOUR PHOTO & SHORT CV

A photo and your credentials will be posted on the Congress website

Layout

Photo • format Jpeg

Click or drag a file to this area to upload.

Summarised CV • please in PDF file and ONLY ONE A4 page

Click or drag a file to this area to upload.

Accompanying person name ~ if required

Accompanying person

Accompanying Person First name, given name

Accompanying Person Middle name initial(s)

Accompanying Person Surname, family name

Accompanying Person special meals requirements (if any)

(e.g.: vegetarian, no pork, no beef, no fish …)

Welcome Reception Nov. 6th

Accompanying persons are welcome.

Please inform if you will attend Welcome Reception

YES
NO

This information will be useful to better plan logistic services

Please inform if your accompanying person will attend Welcome Reception

YES
NO

This information will be useful to better plan logistic services

SOCIAL DINNER NOV. 7th

The Organizing Committee will be honoured to host Faculty Members. Accompanying persons are welcome.

Please inform if you will attend Social Dinner

YES
NO

This information will be useful to better plan logistic services

Please inform if your accompanying person will attend Social Dinner

YES
NO

This information will be useful to better plan logistic services

Special meals requirements (if any)

(e.g.: vegetarian, no pork, no beef, no fish …)

I acknowledge that I have read and agreed to all of the above information as well, privacy policy and warrant all information given above is true

YES
NO

If you do not agree it will not be possible to process your registration