SOUTH EAST ASIA MEDICAL MISSIONS CONFERENCE 2017 REGISTRATION FORM

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FIRST FORM

Full Name *

Nickname *

Gender *

Date of Birth *

YYYY

Residential Address *

(city/regency and country)

Nationality *

Mobile Phone *

(country code +62 813xxxx)

WhatsApp Number *

(country code +62 813xxxx)

Email *

Education Status *

Student

Graduate

Education Institution *

Occupation

for graduate

Current Working Institution *

Medical Missions Calling & Experiences *

(Please explain briefly about your experience and calling in medical mission)

What Do You Expect from this Conference? *

English Proficiency *

Speaking and listening

Average

Good

Speaking

Listening

Allergies *

(foods / meds)

Vegetarian *

Yes

Chronic Medical Condition *

We are pleased to offer a small number of bursaries for students. The amount of coverage (conference fee and/or travel cost to Bali) depends on your financial situation. If you need to get the bursary, please share your financial constraint/situation and email to: seammc2017@gmail.com. Kindly also mention how much fund you can raise/afford yourself

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