Registration Form


NHLS Research Summit 2013
Enriching Health through Research: Paving the Future

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+ Surname is required. + First names required.

+ Preferred name is required.
+ Email is required. + Specify a valid e-mail address.
+ Select if you are a NHLS employee. + Employee number is required.

+ Select if you are HPCSA registered. + HPCSA number is required.

+ At least one contact number is required.

+ Contact in case of emergency is required. + Emergency contact number is required.

+ Institute is required. + Other is required.

+ Department/Research Unit is required.
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+ Delegate status is required. + Other is required.

+ Dietary request is required. + Other is required.

+ Preferred Session Day 1 is required.
+ Preferred Session Day 2 is required.
+ Require Hotel Accomodation is required. + Arrival Date is required.
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+ Require shuttle is required. + Arrival time is required.