The Frontiers of Cell Based Tissue Engaging in Orthopaedics

Registration Form

Contact Information(*must fill)

*Name:(Dr.  Prof.)

(First Name)(Last Name)

*Position:Specialty:

*Department:*Hospital:

CorrespondenceAddress:

Phone:Fax:*E-mail:

*Do you want to join OLC membership to receive notification of upcoming workshops? Yes No

*Applied sponsorship for this program? Yes: ______No

Particulars

No. of years in Orthopaedics:HOT / BST: Year (if applicable)

Other specialist qualification, e.g. FRCS: (if applicable)

Why are you interested in this course?

What are your learning objectives/expectations?

Payment

Please mail your completed registration form together with a cheque payable to “The Chinese University of Hong Kong” to Orthopaedic Learning Centre,1/F Li Ka Shing Specialist Clinics, North Wing,Prince of Wales Hospital, Shatin, Hong Kong.Please send the form to us by email to if you are payingby credit card.

Please complete Credit Card Payment Authorization below if you are using credit card payment.

Please provide the details of your experience in order to offer the mostoptimal grouping to facilitate your needs.

Sub-specialty / Years of experience (please circle the correct ones) / Skills and volume (e.g. 100 cemented hips per year)
Hip / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+
Knee / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+
Spine / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+
Trauma / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+
Shoulder / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+
Elbow / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+
Hand/Wrist / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+
Arthroscopy / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+
Sports Medicine / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+
Cranio-maxillofacial / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+
Pediatrics / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+
Others / 0 / 1-2 / 3-4 / 5-9 / 10+ / 20+