Training workshop on Universal Health Coverage

2ndAfHEA – YRP Training Workshop

APHRC – Nairobi/Kenya, from 18th to 29thAugust 2014

REGISTRATION FORM

This form must be completed by all participants

PLEASE READ THE INFORMATION ON FINANCING AND METHODS OF PAYMENT IN SECTION 3 BEFORE FILLING THIS FORM
SECTION 1A: PERSONAL INFORMATION

*First Name: / Middle Name:
*Surname:
Qualification(s) (eg. Ph.D): / Title (eg., Mrs, Miss , Ms, Prof, Dr)
*Function:
*Organization/Institution:
My organization is involved in universal health coverage in my country
* Postal address:
*City: / *Country:
*Nationality: / *Country of residence:
*Sex: Male / Female:
*E-mail (Main):
E-mail (Secondary):
*Main Phone Number and Type: Mobile
2nd phone number and type: home
3rd Telephone Number and Type: Office
Fax, if available:
/ Skype, if available:
Please indicate your top three areas of interest in Health Economics, health finance or health policy or other related discipline (eg economic evaluation, public health, etc.).

*Required fields

SECTION 2: INFORMATION ON FUNDING AND PARTICIPATION

ALL FIELDS OF THIS SECTION ARE MANDATORY AND THEY MUST BE FILLED OUT

1. / I am a candidate resident abroad (outside Kenya) / I will pay:
Registration fees(150 $)
Travel expenses
I'm looking for funding
2. / I am a candidate resident in Kenya / I have to pay:
-Registration fees (150 $)
3.1 / Please indicate your source of funding: / Myself
Employer / Organization
Other, Status:
4.2 / I wish to pay my participationfees and expenses by / Direct Transfer to AfHEA bank account (see details in section 3)
Cheque
Cash on arrival
Other, specify:
5.3 / To participate in the training, I will travel from (city, country):
/ ■City:
■Country:
6.4 / Travel and stay / I confirm my intention to be hosted by AfHEA
If yes, please specify the period of stay:
I need assistance to obtain a visa to Kenya (invitation letter)[1] :
Transport from the airport to the hotel:
If yes, please provide details on the airline and the estimated time of arrival:

SECTION 3: INFORMATION ON THE COSTS OF PARTICIPATION IN THE TRAINING AND METHODS OF PAYMENT:

Participants are responsible for allexpenses and are required to pay a participation fee for the training.

The costs of participation in the training are as follows:

●Registration Fees: 150$ US.

●Travel and Accommodation: Participants will bear the cost of their travel and accommodation

●Food: AfHEA will provide tea breaks and lunch for participants

AfHEA grantees:

  • Given the limited resources available to AfHEA, the number of scholarships (for travel and accommodation) is very limited and the selection will be based on criteria established by AfHEA. Priority will be given to female candidates and African students studying full time in institutions in Africa and can provide proof of their student status. These would ordinarily be citizens from low income or fragile African countries, in line with AfHEA’s commitment to support its priority target groups.They will however be required to pay only their registration fee of $150.

The training costs are as follows:

  • Direct on-line transfer to AfHEA bank account in the UK, details below:

Account holder: African Health Economics and Policy Association

Name of the Bank: Barclays Bank (United Kingdom)

Account number: 93137317

Bank Sort code: 20 00 77

IBAN code: GB32 BARC 2000 7793 1373 17

BIC or Swift code:BARCGB22

Bank Address: 163-165 Union Street

Aberdeen

AB11 6SL

Scotland, UK

Please check carefully to ensure that you have entered the account number and codes exactly as above in order to avoid any delay whatsoever in resolving your participation fees or any problem whatsoever for your participation.

  • The Cheques are payable to the order of: African Health Economics and Policy Association. These can be paid into our bank account in Ghana by transfer:

Account Name: African Health Economics & Policy Association

Bank Name: Ecobank Ghana Limited

Account Number: 001-206-446-843-8702

Currency: USD

Bank Address: Ridge West, Accra, Ghana

Branch: Head Office Branch

Swift Code: ECOCGHAC

  • Payment onsite for training is also permitted but We do not encourage participants to travel with cash with the intention to settle the costs of participation in the training

For further information, please contact: Felix Abrahams for registration and Grace Njeri <> for Accommodation/Travel

** Please send your completed form in MS Word format (DO NOT SEND IN PDF FORMAT) to: and cc: .Forms in PDF format will be automatically returned to sender

AfHEA: +233-(0)302-797-109, +233 54- 734 7035 – Email: , – Skype: afhea091

[1]Note that some participants from countriesdonot needvisa to enter Kenya. Refer to thefollowingwebsite to checkyour case: