Pre-Registration

Indicate your interest in participating, exhibiting, or contributing to Mednet 2006 by filling in this form. You will then be on our mailing list and we will inform you about upcoming deadlines and the program. The form can also be used to suggest tutorials or panels; however, these are considered informal suggestions, and you still need to submit a full proposal using the abstract submission system (see Call for Papers). Pre-registration is not binding, but we ask below that you indicate the probability that you will attend (using the drop-down box below), in order to facilitate our planning of the congress.

Required

First Name:

Middle Name/Initials:

Surname:

I am a:

Individual JMIR member (D)

Click here to

(* JMIR members get a $100 discount)

become a member

Consumer (get 50% discount)

	Student *if no grant funding is available* (get 50% discount).
	delegate from Developing Country (LIC, LMC, or severely indebted country according to WorldBank) *if no grant funding is available* (get 50% discount).

Proof of student and/or citizen status may be required at the registration desk

Affiliation:

Email:

Street:

City:

State/Prov:

Country:

Postal code:

Phone [home/work]:

extension:

Fax:

Mailing address (optional):

I plan to attend with:

% certainty

I need accommodation

I am interested in presenting a poster

I am interested in submitting a paper for oral presentation

I am interested in compiling a panel (asking 2-3 colleagues to present with me about a certain topic):

Title:

Panel Members (including yourself):

I am interested in giving a pre-conference tutorial (tutorials are paid) with this topic in mind:

Please contact me to arrange exhibition booking:
Budget: $US

I am interested in a software demo table:
Budget: $US

I/we am/are interested in sponsoring the conference:
Budget: $US

Create a Username:

Begin with a letter, and use only letters a-z, numbers 0-9,
the underscore (_), and no spaces. Hint: Your email address can best serve as a username

Create a Password:

Passwords may contain only letters (a-z) and numbers (0-9).

Verify Password:

Please re-enter your password.

Please answer these questions so we can know you better.