Individual registration & accommodation form Please write in CAPITAL letters Prof/Dr/Mr/Mrs/Ms Given (First) Name Given (First) Name on the badge Given (Last) Name on the badge Institution/Organisation/Company Mailing address Gender (Male/Female) Given (Last) Name Please fax or mail this form to: WCP 2012 World Congress on Pain c/o MCI Suisse SA, 75 rue de Lyon, CH-1211 Geneva 13, SWITZERLAND Tel: + 41 22 33 99 593 Fax: +41 22 33 99 631 Email: iasp2012.reg@mci-group.com or register on-line : https://b-com.mcigroup.com/registration/iasp2012.aspx City Postal/zip code Country Tel Country code Area code Number Fax Country code Area code Number Email A. REGISTRATION FE A. Registration fee Registration fee IASP Member* IASP Member Number: Early Fee Up to May 1 st 2012 Regular Fee After May 2 nd 2012 On-Site Fee From August 25 th 2012 EUR 470 EUR 620 EUR 645 IASP Non-Member EUR 555 EUR 705 EUR 730 Delegates from Developing/Currency restricted countries** EUR 170 EUR 170 EUR 170 Trainees*** EUR 125 EUR 125 EUR 150 Daily Pass: Tuesday, August 28 th 2012 EUR 200 EUR 200 EUR 225 Daily Pass: Wednesday, August 29 th 2012 EUR 200 EUR 200 EUR 225 Daily Pass: Thursday, August 30 th 2012 EUR 200 EUR 200 EUR 225 Daily Pass: Friday, August 31 st 2012 EUR 200 EUR 200 EUR 225 Accompanying Guest (max: 3) Amount: EUR 75 EUR 75 EUR 75 * These rates are only applicable to delegates who are current members of IASP as recorded at the IASP Secretariat. Membership in an IASP Chapter is not a qualification for these member rates. Non-member trainees may register at the trainee rate only if an IASP member certifies the registrant s trainee status (IASP member name and email address must be provided during registration). ** List available on IASP website under Grants IASP Developing countries project: Initiative for improving pain education: www.iasp-pain.org *** Non-IASP members must be certified as a Trainee by an IASP member in order to receive the special Trainee rate. Please list the name of a certifying member who can verify your Trainee status. Subtotal to be paid (A) Page 1
Certification of Trainee status: Trainee Member of IASP To certify your membership of IASP, please provide your Membership number: Trainee non Member of IASP I, (IASP Member) certify that the individual registered above is and will still be a Trainee at the time of the Congress. Email (IASP Member): Signature (IASP Member) Delegates' registration fee includes: Access to scientific sessions (Plenary Lectures, Topical Workshops) Access to poster sessions Access to commercial exhibition Delegate materials and bag Abstracts CD and access to online abstract Coffee breaks Welcome Reception, Monday, August 27 th, 2012 Trainee Networking Reception, Tuesday, August 28 th, 2012 (For Trainee delegates only) Invitation letter for visa purpose : I require an invitation letter for visa purpose Passport number: Passport expiry date: Date of birth: Your Nationality/Passport: Medical/Scientific Specialty or Field of Interest : Anesthesiology Dentistry/Oral Medicine Family Medicine/Primary Care Internal Medicine Neurology Neuroscience/Pharmacology Neurosurgery/Surgery Nursing Obstetrics/Gynecology Occupational Medicine/Therapy Oncology Orthopedics/Rheumatology Orthopedics/Rheumatology Palliative Medicine Pediatrics Physical Medicine/Therapy and Rehabilitation Psychiatry Psychology/Social Science Other (please specify): Special Dietary Needs : Vegetarian Vegan Gluten Free Lactose Free Kosher Halal None B. Accompanying persons registration fee 1. Accompanying person s Last name: First name: 2. Accompanying person s Last name: First name: 3. Accompanying person s Last name: First name: Accompanying persons registration fee includes Welcome Reception, Monday, August 27 th, 2012 Delegate materials and bag Hop On, Hop Off Bus ticket (4 days validity) Access to other Congress-organized tours (tickets must be purchased in addition) Page 2
C Optional Excursions/Tours (see description of each excursion from the pdf document attached to the e-mail) OPTIONAL EXCURSIONS/TOURS Time 27th 28th 29th 30th 31st Rate Milan Walking tour (Duomo, Scala & Last Supper) Milan Walking Tour (Duomo, Scala & Brera Picture Gallery Milan Walking Tour and the Sforza Fox Town Outlet Cooking Class in Teatro 7 Como Walking Tour Excursion to Como with Public Boat to Tremezzo and Bellagio EUR 51 EUR 54 EUR 29 EUR 30 EUR 127 EUR 34 Full Day EUR 34 Lake Maggiore and Borromean Islands Full Day EUR 91 Bergamo City Tour Full Day EUR 43 Milan by Bike (incl. visit to the Scala) Milan by Segway TOTAL (2) EUR 73 EUR 151 Excursions on August 31st are only available in the morning. Subtotal to be paid (C) D- Social Events Monday, August 27 th, 2012 17:00-19:00: Opening Ceremony and Welcome Reception, included in the registration fee. Access limited to duly registered participants and accompanying persons. Additional Welcome Reception Ticket 40.00 EUR: Number of tickets: Subtotal to be paid (D) Tuesday, August 28 th, 18:30 20:30: Trainee Networking reception (for Trainee registration only), included in the trainee registration fee. Access limited to duly registered participants. Page 3
E. Refresher Courses Monday August 27 th, 2012 Refresher Courses Early Fee Up to May 1 st 2012 EUR 100 Regular Fee After May 2 nd 2012 EUR 135 On-Site Fee From Aug- 25 th 2012 EUR 165 An update on the Neurobiology of Acute and Persistent Pain Chronic Musculoskeletal Pain update: from basic science to management Headache update - Diagnosis and Therapy Pain Psychology for Non-Psychologists Clinical pharmacology: evidence-based guidelines and defining the proper outcome. Neuropathic pain update: from basic mechanisms to clinical management Interventional therapies for chronic pain: indications and efficacy Rational opioid therapy for cancer and non-cancer pain Treating pain in children: an update Cancer pain update: from mechanisms to treatment The Basics of neuroimaging and brain interference techniques Fundamentals of neuropathic pain assessment and diagnosis Update on the management and treatment of complex regional pain syndrome Orofacial pain for physicians Persistent postoperative pain: pathogenic mechanisms and preventive strategies Pain genes for unraveling pain: a course for non-geneticists Pathophysiology, diagnosis and treatment of persistent The basics, management and treatment of low back pain Emergent alternate therapies for chronic pain Subtotal to be paid (E) Page 4
F. SIG Satellite Symposia Sunday August 26 th, 2012 Each organizing SIG will set its own schedule and will communicate start and end times prior to the Congress. Please tick one SIG Satellite Symposia. All fees shown are in Euro (EUR). SIG SATELLITE SYMPOSIA MEMBER FEE TRAINEE FEE NON-MEMBER FEE (SIG MEMBERS ONLY) Rate Rate Rate The Challenges of Acute Pain Management EUR 70 EUR 70 EUR 70 Neuropathic Pain in People with Cancer EUR 75 EUR 55 Pediatric Pain Management: Challenges and Opportunities: A Symposium of Challenging Pediatric Pain Syndromes: Biology, Pharmacology, Psychology, and Treatment EUR 135 EUR 150 Current Concepts, Methods, and Progress in Pain Genetics Research EUR 175 EUR 175 EUR 175 Biomarkers and Mechanisms in Musculoskeletal Pain EUR 80 Member: EUR 80 Non-Member: Neuropathic Itch EUR 50 EUR 50 EUR 50 Study Design, Analysis and Experimental Reporting EUR 85 EUR 125 EUR 55 Overcoming Challenges in Pain Practice in Older Persons EUR 60 EUR 75 EUR 45 Orofacial Pain Signatures EUR 75 EUR 37.50 International Perspectives on Professional and Public Pain Education: Two Sides of The Same Coin Member: Non-Member: Placebo Effects: Can They be Enhanced in Clinical Practice? EUR 130 EUR 60 Taking Care of the Patient with Chronic Pelvic Pain Vulnerability to Pain: Sources of Female-male Differences and the Challenge of Understanding Them Pain and the Sympathetic Nervous System. A Comprehensive Analysis of CRPs Treatment: The New, the Old, What Works and What Doesn t: How to Integrate Effective Treatment Reliable Evidence in Pain Therapy: Bridging the Gap between Clinical Trials and Clinical Practice Working with Survivors of Torture and Conflict EUR 125 EUR 125 EUR 125 EUR 50 EUR 75 EUR 25 EUR 90 EUR 150 EUR 70 EUR 90 EUR 70 EUR 90 EUR 50 EUR 75 Member: Non-Member: EUR 30 EUR 40 Subtotal to be paid (F) Page 5
G. Hotel Accommodation Reservations are made on a first come, first served basis. Availability of rooms in each category is limited. Name of persons sharing rooms must be indicated by e-mail to MCI Suisse S.A. Rates apply for standard room; other room types like deluxe room, junior suite, suite, etc. are available upon request. All rates are in EURO (EUR) per room, per night, and include buffet Breakfast, services and are all taxes included at the time of printing (September 2011) and subject to fluctuation. Any significant variation may lead to a retroactive increase in the specific hotel rate. Reservation & Payment Only guaranteed reservations will be accepted: to guarantee your reservation a deposit covering the first night is required, either by bank transfer or by credit card (deposits will be deducted from the final hotel bill when paid by the participant at the hotel). After Monday, July 16 th, 2012, midnight CET, only payment made by credit card will be accepted. Large group reservations (more than 9 participants) will be handled by MCI Suisse S.A. with separate contracts. If you need additional dates for your hotel reservation out of the congress dates, please contact directly MCI Suisse S.A. at: iasp2012.hot@mci-group.com. 1st choice 2nd choice 3rd choice Single room Double room Twin room (2 beds) Arrival date: Number of rooms: Departure date: Room rate: Subtotal to be paid* (G) * Total deposit calculation (1 night s stay) = Number of rooms x Room rate TOTAL A+C+D+E+F+G Page 6
CONDITIONS OF PAYMENT Payments: All payments must be made in Euro (EUR). No confirmation will be sent until MCI Suisse SA has received the payment. Please tick the appropriate box By bank transfer, in Euro (EUR).(payment upon receipt of corresponding invoice) Upon receipt of your duly completed registration form, we will issue and send you the corresponding invoice. Payment of this invoice by bank transfer is requested upon receipt. By credit card: I authorise MCI Suisse SA to charge my credit card for the total amount of EUR : American Express Eurocard /MasterCard Visa Cardholder's name: Card number: Security code* Expiry date: Signature and date: * Your card security code is a three or four digit number. For Visa and Eurocard, the code is the last three digits printed on the signature strip on the back of the card. For American Express, the code is the four digits printed on the front of the card Confirmation Confirmation and receipt will be sent on receipt of the registration form and payment. Please retain your confirmation letter for presentation at the Registration Desk in order to receive your meeting documentation and badge. PAYMENTS, CANCELLATION AND REFUNDS Registration: Full payment of these items is requested when registering (by credit card or by bank transfer). No confirmation will be sent until MCI Suisse SA has received the payment. All cancellations must be sent to MCI in writing (fax, letter or email). Registration For cancellations received until Monday, July 2 nd, 2012 deposits will be refunded less EUR 50.00 for administrative costs. After this date, no refund will be possible. Social programme, Excursions: Cancellations can be made free of charge until Monday, July 2 nd, 2012. After this date, no refund is possible. MCI reserves the right to cancel or modify the excursion program if the minimum participation is not reached or due to factors beyond the control of the organisers. Modification conditions A handling fee of EUR 45.00 per registration will be charged for every registration modification received after Monday, July 16 th, 2012. For a badge name change, a written permission from the original participant will be required, along with full contact details of the substitution. In case of a lost or forgotten badge, an administrative fee of EUR 50.00 will be charged for the reprint of the badge after verification of identification (passport, driving license or other recognized identification paper). Hotel: All changes must be sent to MCI Suisse SA in writing (email or fax). Please do not contact the hotel directly. In case of cancellation up to 2 nd July, 2012 deposits will be refunded less EUR 50.00 for administrative costs. After this date, deposits will not be refunded under any circumstances. In case of late cancellations (after July 2 nd, 2012), rooms cancelled, cancelled nights or no show, 1st night stay will be retained and we reserve the right to charge the full stay if the hotel room cannot be re-sold. A modification handling fee of EUR 45.00 per room will be charged for every change received after July 16 th, 2012.. Page 7