ONLINE REGISTRATION FORM

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ASM 2017 Meeting Secretariat
International Conference Consultants Ltd.

Unit C-D, 17/F, Max Share Centre, 373 King's Road, North Point, Hong Kong
Tel: (852) 2559 9973      Fax: (852) 2547 9528       Email: asmhk@icc.com.hk      Website: www.anaesthesiology.hk

  (A) PERSONAL INFORMATION * Mandatory fields
 
Title: * Others, please specify:
Last Name: *
First Name: *
Position: *
Department:
Institution/Hospital: *
Address: *
 
 
City/State:    
Postcode: Country: *
Tel: *
(Country code)(Area Code)(Telephone number)
Fax:
(Country code)(Area Code)(Telephone number)
Email: *
(Email is required for future communication.)
 
(Please type your email again for verification.)
Dietary Requirement: Vegetarian Allergic to Food (Please specify: )
 
  (B) REGISTRATION FEE

Scientific Symposia (17 - 19 November)

Venue of the programme on 17 Nov: The Harbourview
Venue of the programme on 18-19 Nov: Hong Kong Convention and Exhibition Centre
Category
Early-Bird Rate
(on/before 31 October 2017)

Regular Rate
(after 31 October 2017)

HKCA Fellow and Delegate from the High Income Economies Countries 1, 2
HK$3,500
HK$4,000
HKCA Trainee *1
HK$1,000
Non-HKCA Trainee *1
HK$2,000
Delegate from the Countries other than those High Income Economies Countries 1, 2
HK$2,500
HK$3,000
Allied Health Professional
HK$1,000

The above registration fee is applied for a 3-day meeting but registration for the programme on 17 Nov is subject to a limited quota and on a first-come-first-served basis. Nursing Symposium is NOT included.

Scientific Symposia on 17 November (subject to limited quota):  FULL Yes, I will attend.    No, I will not attend.


Nursing Symposium (09:00 – 12:30, 18 November)
For Nurse Only:
Nursing Symposium ONLY
HK$700
Nursing Symposium & Scientific Symposia
HK$1,500
    Sub-total (B): HK$     
*  Verification letter from the Department of Anaesthesiology in your hospital is required to qualify for the Trainee fee.
1 ASM Registrants (except Nursing Symposium only) are entitled to Scientific Symposia, exhibition, tea breaks, Breakfast Symposium, Lunch Symposia, and Congregation Dinner.  Nursing Symposium is not included.  Limited number of light breakfast and lunch will be available at Breakfast Symposium and Lunch Symposia respectively on a first-come-first-served basis.
2 List of high, middle and low-income economies countries as per the World Bank Classification for the current to 2018 fiscal year: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups
  The organizers reserve the right of offering concession rate to particular registrants.  Further proof may be required by the Meeting Secretariat before processing. The offer is on a first-come-first served basis and subject to quota.


Please indicate the function(s) that you will join.   (Seating is limited and allocated on a first-come-first-served basis).
Lunch Symposium
        (18 November)
Breakfast Symposium
        (19 November)
Lunch Symposium
        (19 November)
Congregation Dinner
        (19 November)


  (C) OPTIONAL WORKSHOPS

Venue of W1 and W5: The Harbourview
Venue of W2, W3, W4, W6, W7 and W8: Hong Kong Convention and Exhibition Centre
Workshops
Fee
W1 – Echo Wet-Sim Workshop (West China Method) (17 November, 09:00 – 17:00)
                          HK$2,000
W2 – Patient Blood Management Workshop “PBM, Improving Patient Outcome through PBL”
          (18 November, 11:00 – 12:30)
                          HK$500
W3 – Critical Care Ultrasound Workshop (18 November, 13:30 – 17:00)
                          HK$2,000
W4 – Pediatric Airway Workshop (19 November, 09:00 – 12:30)
                          FULL HK$1,200
W5 Simulation-Based Workshop on Perioperative Application of Focused TTE/TOE (19 November, 09:00 – 12:00)
                          HK$1,500
W6 – Regional Pain Workshop  (19 November, 11:00 – 12:30)
                          HK$1,000
W7 – ADAM-B Airway Workshop (19 November, 13:30 – 17:00)
                          HK$2,000
W8 – Anesthesia Cooking Class – Preventable Pitfalls in Haemodynamic and Cerebral Monitoring
          (19 November, 13:30 – 15:00)
                          HK$500
Sub-total (C)
HK$
Only ASM Registrants are eligible to register for the workshops.  Registration is on a first-come-first-served basis. Workshops may be cancelled due to insufficient enrolment.

  (D) ADDITIONAL DINNER TICKET(S) 

Congregation Dinner on 19 November
(one complimentary ticket to each ASM registrant except those join Nursing Symposium only)
Amount
Additional Ticket(s): HK$1,280 per person x ticket(s)
HK$
(Please notify the Meeting Secretariat by email if there is any dietary requirement.)

  (E) PAYMENT DECLARATION

I hereby agree to be bound by the rules and regulations of the Meeting and would like to settle the payment (Part B+C+D) in HK$ by:

 
Cheque (in Hong Kong dollars only) payable to “The Hong Kong College of Anaesthesiologists
(Please mail it to the ASM 2017 Meeting Secretariat. Address is:
International Conference Consultants Ltd.: Unit C-D, 17/F, Max Share Centre, 373 King's Road, North Point, Hong Kong.)
Credit Card (in Hong Kong dollars only)
(Please contact your credit card company to notify them of this international charge to prevent the transaction from being rejected.  The merchant name shown on the statement will be ICC LTD and the amount charged will be in HK$.)
I hereby authorize International Conference Consultants Limited (ICC Ltd.) to debit my account for the above-mentioned amount.
VISA     MasterCard    
Card No. - - -
Name of Cardholder
Expiry Date / (MM/YY)
If the delegates are not using personal credit card to pay, please fill in the following details of the cardholder.
Contact Email:      Contact Phone no.:
Rules and Regulations:
1. Each registrant should complete a separate Registration Form. 
2. Registration without payment will NOT be processed.  Please do NOT send cash.
3. The Meeting Secretariat will send a registration confirmation by email upon receipt of your registration form and full payment.  Kindly check the confirmation.  Any changes or alterations must be made in writing to the Meeting Secretariat.
4. Refund for cancellation of registration will be made and subject to the following deadline and administrative charge:
On or before 18 October 2017 50% of the registration fee
After 18 October 2017 No refund
5. The programme is subject to change without prior notice.  In the event of cancellation of the Meeting, the only liability of the Organizers is to refund all the fees paid. Workshops may be cancelled due to insufficient enrolment. Refund will be made after the Meeting.
6. All enquiries, changes and cancellations should be made in writing to the Meeting Secretariat.
7. The information on this Form is to assist us in preparing your participation in the Meeting.  All the information you provide will be restricted to the Organizers of ASM 2017 and other related working parties.  You have the right of access and correction with respect to your personal data held by us.  If you wish to exercise these rights, please contact the Meeting Secretariat.

I hereby agree to abide by the rules and regulations of ASM 2017 Meeting.