Partnering Associations

Co-sponsored by

World Health Organization

South-East Asia Regional Office, Delhi

ISMOPH - REGISTRATION FORM

PERSONAL INFORMATION (Please use BLOCK LETTERS)

Title:

Prof

Dr

Mrs

Ms Mr

Name:_____________________________________________________________________________________________________
First name (Given name)

Middle name

Last name (Family name)

Designation /Position:_________________________________________________________________________________________
Organisation:________________________________________________________________________________________________
Street Address:______________________________________________________City:________________State:________________
Country:_________________________________________________ ZIP /PIN/ Post Code:_________________________________
Phone:_______________________ Fax:______________________Email: ______________________________________________
(only the one you use most frequently)

REGISTRATION FEE: (AMOUNT IN INR)

REGISTRATION CATEGORY

FEES (INR)

PUBLIC HEALTH PROFESSIONALS

` 2000

POST-GRADUATE STUDENTS

` 1500

UNDER-GRADUATE STUDENTS

` 1000

All rates are inclusive of currently applicable service tax @ 12.36%

Trainees/Students will need to provide a certicate from the Head of Department or Institution conrming eligibility

Please Note:

Registration for ISMOPH does NOT include registration for the main 14th World Congress on Public Health from
11-15 February, 2015. ISMOPH participants wishing to attend the Congress should register separately for 14th World
Congress on Public Health.

ISMOPH WORKSHOP PREFERENCES

Please indicate your preferences by ticking one Workshop in each of the three sets below. Note that your selections will determine the
size of rooms to be used for the Workshops. Seats in the Workshops will be on rst-come-rst served basis. To guarantee your place
in your preferred workshop please come early and take your seat.

9 February 2015, 09:30-15:30 - Tick only one Workshop in the box next to it.
CAPACITY-BUILDING WORKSHOPS

TICK ONE

SCIENTIFIC WRITING
SOCIAL DETERMINANTS OF HEALTH WHO
DISASTER MANAGEMENT NDMA
COMMUNITY MENTAL HEALTH CARE TIME TO CHANGE
HEALTH ECONOMICS
SHARING RESPONSIBILITIES & RESULTS FOR AN AIDS FREE GENERATION

10 February 2015, 09:30-15:30 - Tick only one Workshop in the box next to it.
CAPACITY-BUILDING WORKSHOPS

TICK ONE

GENERATING EVIDENCE IN PUBLIC HEALTH

PUBLIC HEALTH EDUCATION DEVELOPING NEED BASED COMPETENCIES
CREATING A HEALTH YOUTH DIVIDEND UNFPA
FOOD SAFETY & FOOD BASED ZOONOTIC DISEASES
AGEING POPULATION GROWING CONCERN

10 February 2015, 15:30-17:00 - Tick only one Workshop in the box next to it.
SHORT WORKSHOPS
NUTRITION EDUCATION LEADERSHIP FOR IMPROVED CLINICAL OUTCOMES - NNEd Pro, UK
ROLE OF PUBLIC HEALTH PROFESSIONALS IN OUTBREAKS
ENVIRONMENTAL DETERMINANTS OF HEALTH
GEOSPATIAL DATASETS: OPENING UP NEW DIMENSIONS IN PUBLIC HEALTH - INCLEN
PROSPECTS IN PUBLIC HEALTH MANAGEMENT & RESEARCH IIHMR
PUBLIC HEALTH ADVOCACY TRAINING WORKSHOP IFMSA

TICK ONE

PAYMENT OPTIONS
Please note that bank transfer charges are to be paid by delegate. Please add bank transfer charges to the
amount you pay to your bank. Banks will deduct processing fees from the amount transferred, which could result in your registration
being incomplete. To avoid this, please add the bank transfer charges to the amount you pay to your bank.
After the bank transfer, please ask for a Payment/Transaction Advice from your bank. Send the advice with the completed form to
the congress secretariat, to identify you and conrm your payment. Registration Forms indicating payment by Bank Transfer but
received without copy of Payment Advice will not be considered.

ISMOPH Secretariat

CANCELLATION & REFUND POLICY

On or before January 01, 2015 - 25% cancellation fee will be charged.

After January 01, 2015 - No Refunds (100% cancellation shall be applicable).
Cancellation to be emailed to the Congress Secretariat at: ismoph2015reg@kwconferences.com Verbal communication not
admissible.
Date of receipt of communication for cancellation will be used for calculating amount of refund.
Refunds will be credited only to the account from where the registration amount was received.
All refunds will be processed 30 days after closure of the Pre-Congress Workshop.

Delegates Signature___________________________________Date:____________________

ISMOPH Sceretariat
KW Conferences Pvt. Ltd.
A-56/12, DLF Phase-I, Gurgaon-122002,Haryana, India
Email: ismoph2015reg@kwconferences.com
Ph: +91 124 4636700, Fax: +91 124 4102075