Registration Form

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Hull York Medical School Student Research Society Conference 2019

Allam Medical Building, University of Hull, Cottingham Road, Hull, HU6 7RX

7^th December 2019

Register for the Conference

To ensure that confirmation of place is not delayed, could you kindly state if you are registering and paying for this course/event for yourself or on behalf of someone else?

I am registering and paying for myself

I am registering and paying on behalf of someone

Please provide YOUR DETAILS so that we can match the payment with the candidate's details in our system.

Forename

Surname

Address

Country

Pin code/Post code/ Zip code

Phone number (including country code if outside the UK)

Please state your relation to this candidate