EEEM Preparatory Course 2017

Hong KongSociety for Emergency Medicine and Surgery

EEEM Preparatory Course 2017

Date: 8th - 9th June, 2017

Venue:H702 Seminar Room, Block H, Princess Margaret Hospital

Time:9:00 – 18:00

Maximum Seats:16

Program

Lectures

Small group practice

Mini-mock exam

Fee

HKD 6,000

Entry Criteria

Participants must be HKSEMS members. Please send HKSEMS membership application form together with this registration form if you are not yet a member.

Priority will be given to those who will sit for EEEM in 2017.Other applications will be accepted on a first-come-first-serve basis.

Deadline for Application

30th April, 2017

Hong Kong Society for Emergency Medicine and Surgery

Exit Examination of Emergency Medicine Preparatory Course

Application Form

(For Members of HKSEMS only)

NAME (in Block letters) :______

Hospital: ______

Will you sit for EEEM in 2017? Yes/No/Uncertain (please delete the inappropriate)

Mobile Phone: ______

E-mail: ______

Deadline for Application: 30thApril, 2017

This workshop is intended for HKSEMS members only. Please send HKSEMS membership application form (with a separate cheque of appropriate amount), together with this application form if you are not yet a member.

Successful applicants will be informed by email not later than 12th May, 2017.

Payment Method

Please complete the registration form and send a crossed cheque of HKD 6,000 payable to “Hong Kong Society for Emergency Medicine and Surgery Limited”to the following address:

Ms. Sonia HUEN, HKSEMS Secretariat, Rm 809, Hong Kong Academy of Medicine Jockey Club Building, 99 Wong Chuk Hang Road, Aberdeen, Hong Kong

Cheques will only be encashed for successful applicants.Cheques of unsuccessful applicants will be kept at our secretariat for one month for collection.

For enquiries, please email to: contact Sonia at 2871 8874.

Remark: Carparks areNOT available.

Hong KongSociety for Emergency Medicine and Surgery

IMPORTANT NOTICE

1. Full and punctual attendance is required throughout the Course.
2. The application deadline is 30th April 2017. Please complete and return the Application Form on or before the deadline.
3. Successful applicants will be informed by email not later than 12th May, 2017.

APPLICANT’S DECLARATION

1.I declare that the information I provide in support of this application is accurate and complete. I understand that my application will not be accepted if any information or document I provided is found to be false even though payment has been made. I understand and accept that no refundwill be arranged in this case.

2.I confirm that I have read and accepted the Personal Information Collection Statement attached to this Registration Form.

3.I authorize the HKSEMS to check, use and process my data as required for my application.

4.I understand that upon application, my data will become a part of my record and may be used for all purposes in connection with the processing of the application.

Signature / : / Date / :

Personal Information Collection Statement

1. This is a statement to inform applicants of their rights under the Personal Data (Privacy) Ordinance (the Ordinance).
2. The personal data collected in this Registration Form will be used by the HKSEMS for the purposes of organizing the Exit Examination of Emergency Medicine Preparatory Course, and where applicable, will serve as part of an applicant’s official record with the HKSEMS.
3. Personal data will be kept confidential and handled by the staff of or persons appointed by the HKSEMS to undertake its administrative functions and for training purposes.

Note:

a)Applicants are required to keep the HKSEMS informed of any changes in their personal data once they have enrolled for the Exit Examination of Emergency Medicine Preparatory Course.

b)Under the Ordinance, applicants may have the right to request access to, or correction of any data provided by them in relation to their application.

c)As the Ordinance allows, the HKSEMS has the right to charge a reasonable fee for the processing of any request for data access. Applicants who request access to data or for the correction of their data should do so in writing to the HKSEMS.

d)Applicants should write to the HKSEMS if they do not want to receive any information on courses, events or functions organized by the HKSEMS.

FOR INTERNAL USE

Course Registration: /  Accepted  Rejected
Cheque Received
if Registration Accepted (if applicable): /  Received ( Cheque Amount: HK$ ______)
Bank & Cheque No.: ______