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REGISTRATION
Mathematical Physiology:Better Health Through Mathematics
November 1 - 30, 2019
* MANDATORY FIELDS
IDENTIFICATION*
TITLE*
Ms
Mr
Dr
Professor
Professor Dr
NAME*
Given Name
Family Name
OCCUPATION*
FACULTY/RESEARCHER - WITH GRANT
FACULTY/RESEARCHER - WITHOUT GRANT
POSTDOCTORAL FELLOW
GRADUATE STUDENT (2ND AND 3RD CYCLE)
UNDERGRADUATE STUDENT
ELEMENTARY OR SECONDARY SCHOOL PROFESSOR
INDUSTRIAL RESEARCHER (Industry, Finance, etc.)
UNEMPLOYED
SELF-EMPLOYED
Other
Gender* (for statistical purposes)
Female
Male
Prefer not to answer
Language of correspondence*
English
Français
AFFILIATION*
Affiliation
Department
Address of Affiliation
City
Postal Code / Zip Code
Please choose a country:
Please choose a state, province or area:
CORRESPONDENCE ADDRESS
Please fill out the following if different from the affiliation.
Correspondence address
Address
City
Postal Code / Zip Code
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TELEPHONE (with dialing code), EMAIL ADDRESS AND WEB SITE
Email address*
Secondary email address
Office phone*
Home phone
Fax
Cellular Phone
Web Address
Twitter
REGISTRATION FEES*
Registration fees are non-refundable.
Registration Fees $CAN
Please choose
Student
Postdoct Fellow
Faculty
Industrial Researcher
Organizer
Speaker
ATTENTION MANDATORY: PLEASE INDICATE WHICH WORKSHOP YOU WILL ATTEND?
Registration fees include the three workshops within Mathematical Physiology:Better Health Through Mathematics Semester.
(1) November 4-6, 2019 - Workshop on Dynamical disease: from the blackboard to the bedside
(2) November 11-13, 2019 - Workshop on Dynamical diseases and mHealth: chronic disease
(3) November 20-22, 2019 - Workshop on Dynamical disease and mHealth: treating rare events
MANDATORY: Please write the number(s) corresponding to the workshop(s) you will attend: (1), (2) and/or (3)
TOTAL FEES
Total fees $CAN
PAYMENT *
Only payment by VISA or Master Card is accepted. Integrated debit credit card refused.
Credit card information must be valid until the beginning of the workshop.
The following amount will be debited from your credit card.
Payment Card
Name of the credit card holder
Credit card number
Expiry date on credit card MM/YYYY
Your three numbers or CVV (Card Verification Value):
MISCELLANEOUS INFORMATION
Please write any other information or comment.
