Registration Thank you for your interest in the Leopoldina Symposium. Please fill out this form to register. Your data will only be used for internal processing of your registration. Address*MrsMrTitleName* First Name Last Name Postal address Street Address Address Line 2 City ZIP - Country Please enter your address here if you wish to receive a confirmation. Please note that the confirmation can only be sent after we have received your payment and cannot be a proper invoice.Telephone numberE-mail address* Enter Email Confirm Email Use your @charite.de address to receive employee discount.Mode of paymentIf you wish to receive a confirmation, please select 'transfer' as mode of payment, enter your address above and follox the instructions presented after you have completed this form. We will gladly issue you your receipt at admittance.TransferCash at admittancePromotion CodeCodeDiscount Price: 0,00 € Terms & conditions*Registration: By registering for an event you acknowledge the terms and conditions. Confirmation: We will inform you in written form if your registration is confirmed or if you have been placed on the waiting list. Certification: The symposium is accredited by the Ärztekammer Berlin, and 12 continuing education points will be provided for attendance. Cancellation: Please inform us if you are unable to attend the event you have registered for. Cancellation up to 2 weeks in advance is free of charge. If you cancel less than 2 weeks in advance, we will keep a handling fee of 50% of the participation fee. You may send a substitute participant to take your place. If you do not attend without prior written notice, your participation fee cannot be refunded. Cancellation by the organizer: We reserve the right to cancel or reschedule events. Your participation fee will then be refunded. Direct or indirect costs caused by the cancellation or rescheduling cannot be reimbursed. I have read and understood the terms & conditions. Ticket*Scientists (incl. MD)NursingStudentESICM memberDGAI memberOtherEmployee discount I am employed at Charité. Employee discount I am a nurse at Charité. Employee discount I am a student at Charité. Employee discount I am employed at Charité. Employee discount I am employed at Charité. Employee discount I am employed at Charité. Proof*Please upload a valid certificate of enrollment.Accepted file types: jpg, tiff, pdf.Proof*Please upload a valid proof of membership.Accepted file types: jpg, tiff, pdf.Proof*Please upload a valid proof of membership.Accepted file types: jpg, tiff, pdf.Fee exc. tax 0,00 € Save and continue later This iframe contains the logic required to handle AJAX powered Gravity Forms.