Delegate Details

Delegate details:

Delegate #1

Title First Name Last Name

Organisation Job Title

Mailing Address

Email Tel No Fax No

I am: Patient o Carer o Family member o Professional o

I need: El-bed o Lift o Shower chair o Other helping aids______

Any other requirements______

Delegate #2 (if applicable)

Title First Name Last Name

Organisation Job Title

Mailing Address

Email Tel No Fax No

I am: Patient o Carer o Family member o Professional o

I need: El-bed o Lift o Shower chair o Other helping aids______

Any other requirements______

Main Carer’s Details:

Title______First Name______Last Name______

Organisation______Job Title______

Mailing Address______

______

Email______Tel No:______Fax No:______

Additional Carers:

Title______First Name______Last Name______

Registration Fees

Delegates Eur 160 x ___ Main Carer Eur 160 x ___ Additional Carers Eur 160 x ___

The registration fees are inclusive of refreshments and coffee breaks and the Big Dinner on the 22nd August.

Total registration fees (Delegates + Observers + Carers + Additional Carers): EUR_____

Payment Method

Bank Transfer

Send Bank Transfer Payments to:

The organization of people with special needs MOTUS VITA

Registration nr. 40008143545

Bank: "SWEDBANK" AS
Bank account: LV07HABA0551032871057
BIC/S.W.I.F.T.: HABALV22

Please return your completed form by 1 July to:

The address of conference:

SIVA hotel

71 Dubultu prospekts,

Jūrmala, LV – 2015

Telephone: (+371) 67767045

Fax: (+371) 67767518

Web page of the hotel: http://www.hotelsiva.lv/prices.html

E-mail:

For room booking: You have to write a letter-room booking to the e-mail . You have to mention that it is for the conference “11 Nordic ALS/MND Conference”. There should be written the following:

1. Name and Surname

2. Date of Birth

3. Period of booking

4. Requirements (that you will be on the wheelchair, that you need an el-bed and a shower chair and so on)

Then you will get an invoice for paying. (They will offer you the appropriate room) Room reservation is not valid until you get the invoice. Try to do it ASAP as there are not so many specially equipped rooms for disable people.

If you would like to use additional rehabilitation programs, visit http://www.hotelsiva.lv/prices.html and add this information to your booking letter.

If you need special transport Airport-Siva Hotel, Siva hotel-Airport, you should inform us so we can order it for the appropriate time of you arrival.

The price is 35 Eur (2 wheelchairs + 5 assistants), Airport - HotelSIVA

Kind regards

MOTUS VITA