Print / Fax Registration Form   Fax To Dr. Hediger at (617) 525-5821

Please Print this form, do not attempt to fill out this form with your web browser.

Before filling out this form, please submit your application form. Once you receive notification of acceptance, fill out this registration form.

Candidate Information   type or print neatly
 
First Name: Last Name:  
Affiliation/Institution:   
Street Address:Dept. / Building:
City:State/Province:
Postal Code:Country:  
Telephone:E-mail:  
Fax:  


Lodging Rates are per person in Swiss Francs (SFR) or US dollars.
Includes lodging, meals, 1 buffet, 2 special dinners and 1 excursion
Hotels will be reserved between Sunday evening August 8th and Thursday morning August 12th.
Lodging Information

Note: Conference organizers will make all hotel arrangements, all conference attendees will be notified as to their hotel name. Transportation between hotels and Monte Verita conference center will be provided. *Luxury accommodations are 3-Star or better.

Please circle

Register before July 20th for a discounted price
 Single StandardSingle Luxury*Double StandardDouble Luxury*Triple (limited avail.)
Academic Conferee1000SF/675US1200SF/815US800SF/545US900SF/615USN/A
Industry Conferee1100SF/745US1300SF/885US900SF/615US1000SF/675USN/A
Student/Post Doc700SF/475US1000SF/675US500SF/345US600SF/415US400SF/275US
SpouseN/AN/A700SF/475US800SF/545USN/A


Register after July 20th at the following rates
 Single StandardSingle Luxury*Double StandardDouble Luxury*Triple (limited avail.)
Academic Conferee1075SF/735US1275SF/865US875SF/595US975SF/665USN/A
Industry Conferee1175SF/800US1375SF/935US975SF/665US1075SF/735USN/A
Student/Post Doc775SF/525US975SF/665US575SF/395US675SF/465US475SF/325US
SpouseN/AN/A775SF/525US875SF/595USN/A

Rooming Information  
Please indicate name of guest / roommate (s):

1)
2)

Please select a roommate for me.

  
MaleFemale 
Please Indicate:

 
Arrival Date: Departure Date:
Payment Information

By Check:

Check will follow
Check enclosed
Payment by check should be made out to Dr. Matthias A. Hediger. Checks must be guaranteed bank checks. Checks must be drawn from a US or a Swiss bank, either in US dollars or Swiss Francs. Send your check and a completed registration form to:

Matthias A. Hediger, PhD
Harvard Institute of Medicine
Renal Division, Room 570
77 Avenue Louis Pasteur
Boston, MA. 02115
USA

By Credit Card: 
Please Circle: Master Card | American Express | Visa 
Card No. Expiration Date (MM/DD/YY):
Today's Date:Signature: ________________________