Registration Form for the Fifth International Conference on Violence in the Health Sector
Please, send (or fax to ++ 31 (0)20 409 0550) your completed registration form and indication of payment to: Oud Consultancy & Conference Management, Hakfort 621, 1102 LA Amsterdam, the Netherlands.
Conference / Dinner fees Please tick the appropriate boxes and fill in with how many persons you will attend the Conference Gala Dinner.
Congress fee
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Country Category
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Bank transfer
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Creditcard
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A (see reference)
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€ 649,-
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€ 675,-
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B (see reference)
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€ 549,-
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€ 571,-
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C (see reference)
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€ 399,-
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€ 415,-
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D (see reference)
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€ 299,-
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€ 311,-
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Fee is being waived
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€ 000,-
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€ 000,-
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Conference Gala Dinner fee
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Number of persons: x
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€ 75,-
= € ,-
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€ 79,-
= € ,-
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Total
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€ ,-
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€ ,-
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I declare that I have read the general information and registration and payment conditions and I agree with the release and waiver of liability policies, the disclaimer, as well as the policies regarding cancellations and registration refunds.
In consideration of my participation in the fifth International Conference on Violence in the Health Sector, I do hereby release, discharge and hold harmless Oud Consultancy and supporting organizations, from any and all liability by reason of any damage, loss, expense, or injury arising from my participation in this event, including that caused solely or in part by the fault (including but not limited to negligence, gross negligence, and recklessness) of the above-named parties. This release and Waiver of Liability shall be binding on my heirs, executors, administrators, successors, and assigns.
Payment (no cheque)
Please select payment method:
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