VIth World Congress on High Altitude Medicine
Registration Form
(Deadline: 1 June 2004)
PLEASE COMPLETE (PRINT OR TYPE) AND FAX OR MAIL ALONG WITH YOUR PAYMENT, TO THE ADDRESS INDICATED BELOW
Mail or Fax this Form to:
International Society for Mountain Medicine,
5390 N Academy Blvd, Ste 310, Colorado Springs, CO 80918 USA
Phone +1-719-572-1372
Fax +1-719-572-1514, 1-800-967-7494 (USA only)
Email: membership@ismmed.org
I. I
DENTIFICATION
(Please print on computer or type)
Please complete this section carefully. The information you provide will help us to correspond with you efficiently.
Last Name: ________________________ First Name: _____________________ Degree: ______
Institution: _____________________________________________________________________
Address: _______________________________________________________________________
Street: ________________________________________________________________________
City: _____________________________ State/Province: _________ Country: _______________
Postal/Zip Code: _________________ Tel.(day): ________________ Fax: __________________
Email address: __________________________ First Name for Badge:_____________________
II. R
EGISTRATION
(in US dollars)
Regular $400 ____
ISMM Member $350 ____
Student $250 ____
From Less developed Country
(See list at www.ismmed.org/gdp.htm)
$300 ____
Accompanying Person $200 ____
III. P
AYMENT
Registration Fee for Participant
$______
Registration Fee for Accompanying Person
$______
ISMM Membership
(see www.ismmed.org/ismm_membership.htm)
$______
Total
$______
M
ETHOD OF
P
AYMENT
q Option 1: Credit Card:
I hereby authorize ISMM to debit my credit card account for the total amount indicated above.
This
processing these charges for the ISMM. You will receive a receipt from the ISMM at the conference, or by
email if you wish.
q Visa
q MasterCard
Card Number: _________________________________Expiration Date:_________
Cardholder Name: ________________________
Signature of Cardholder: ___________________
q Option 2: International Money Order
These must be in U.S. currency only, payable to ISMM. Your name and address must be clearly indicated.
q Option 3: Check
(for US delegates)
These must be made payable to ISMM. If you are sending a personal check your name and address must be
clearly shown on the front of the check.
Note: June 15
th
, 2004 is the deadline for registration fee refund (less 20% administration fee)
