COMPANION ANIMAL OUTREACH PROGRAM REGISTRATION FORM
September 24-25, 2016

IDENTIFICATION

Please complete this section accurately. The information you provide will allow us to correspond with you efficiently.

Participant

Family Name Initials First Name

Title  Prof.  Dr.  Mr.  Mrs.  Ms

E- Mail Address ______@______Mobile phone: ______Country code / mobile number

Office Address

InstituteDept.

No.StreetSuite/Apt.

CityState/ProvinceCountry Postal code

Telephone (office hours): Country code/city code/number Fax: Country code/city code/number

Veterinary Qualifications

Veterinary School / University______

Registered / Licensed______

State /Province _______

Country _______

Year of Graduation_______

Years in Practice_______

Type of Practice_______

Name of Veterinary Associations you are a member of: _______

You and Your Privacy
please note that companies may be offered the opportunity to hold Satellite Symposium at this specific event.
As a Congress registrant, your mailing details may be forwarded to companies organizing Satellite Symposia. Companies receiving your mailing details will be permitted to use your details one time only for the purpose of sending you Satellite Symposia invitations. Under the Laws of Privacy, you are entitled to object at any time to the processing and usage of your mailing details.

I DO NOT wish my details to be forwarded to companies organizing satellites.

REGISTRATION FEE (in USD)

Registration fee Outreach at Cartagena,Colombia Sep 24th and 25th 2016 – 205$

Required:

Digital copies of:

  • Letter of Good Standing from your Veterinary / Board / Council /Licensing Authority
  • A copy of your veterinary licence or your Veterinary Registration number
  • A copy of your passport
TERMS AND CONDITIONS

WSAVA Volunteers:

1. Are responsible for all costs and expenses related to their participation in the Outreach Program, including but not limited to all expenses for accommodation And travel to/from the local lodging in Cartagena.

2.Are responsible for obtaining all travel documents / visas, adequate medical & travel insurance, and all pre-travel vaccinations & prophylactic medications.

3.Must take due care in respecting the culture, traditions & beliefs of the local community.

4.Must follow all reasonable directives from WSAVA during the Outreach program.

5.Must be members of a WSAVA association.

6.Must be attending the WSAVA 2016 Congress in Cartagena.

7.Agree to indemnify WSAVA against any claim, loss or damage arising now or in the future out of any act, negligence or omission in their preparation for or during their stay or in connection with any work related to the Outreach Program.

8.Agree to indemnify WSAVA against any claim, loss or damage arising now or in the future should project cancellation occur in circumstances beyond WSAVA’s control.

9.Agree to and permit use for publicity purposes of any images (e.g. photographs), interviews undertaken during the Outreach Program by either the project or WSAVA

Date Signature