Registration Form

MCC 2012

FORUM

BULGARIA

NEUROSCIENCE, REHABILITATION, & POLICY

FROM BASIC MOTOR CONTROL TO FUNCTIONAL RECOVERY:

INTERNATIONAL HEATH CARE PERSPECTIVES ON

NEUROSCIENCE-INFORMED DIAGNOSIS & TREATMENT

Please complete this REGISTRATION FORM and send by Email

PARTICIPANT Information:

Please complete the following form carefully

The information you provide will allow as to correspond with you efficiently and will be also used for your

PARTICIPANT BADGE at the MCC2012 Motor Control Conference:

Please type or print in BLOCK LETTERS!

HEALTHCARE FORUM From Science to Medical Practice = QUALITY of LIFE

Motor Control Conference MCC 2012

REGISTRATION FORM

PARTICIPANT

Surname:___________________________________Initials:______

First: name:___________________

Tittle: ___________ (Prof. Dr. Mr. Mrs. Ms )

Address of the Participant: ____________________________________________________

Institution:____________________________________________

Department ___________________________________________

No:__________Street ____________________

City_______________________State/_______________________COUNTRY____

Telephone (country code/city/number)____________________________

Fax:______________________

Email:_____________________

Special requests: ____________________________________________

ACCOMPANYING PERSONS:

Surname:___________________________Initials:______First name:_______________

Surname:___________________________Initials:______ First name:_______________

Special requirements: ________________________________________

I will be attending the Get Together PARTY

I will be attending the Evening Motor Control Conference MCC DINNER

I will be attending the FOLK DANCE DINNER

REGISTRATION FEES:

Please contact us for detailed Information

PAYMENT to MCC2012:

you will be provided with BANK coordinates

You will be handed CERTIFICATE OF ATTENDANCE of the

MCC2012 MOTOR CONTROL CONFERENCE –

FORUM on NEUROSCIENCE, REHABILITATION, & POLICY