THE 33RD ASIAN MEDICAL STUDENTS CONFERENCE 2012

ASIAN MEDICAL STUDENTS ASSOCIATION (PHILIPPINES)

University of Santo Tomas University of the Philippines - Western Visayas State University Our
Lady of Fatima University

AMSC 2012 Philippines Registration form

Please fill in this form carefully and accurately
*Delete accordingly

I. Personal information
Name (as in
passport)
Nickname (for
name tag)
Gender
Date of Birth
(DD/MM/YY)
E-mail Address
AMSA Chapter
Home Address
Contact Number
(with country
code)
University
Passport Number
Passport Expiry
Date (DD/MM/YY)
Team Position
Meal Restrictions

Year of Study
Country of Issue
T-Shirt Size

II. Emergency Contact Numbers

Contact Person 1

Contact Person 2

Name
Relationship
Contact Number
(with country
code)
Home Address
E-mail Address

III. Health Condition

Major Medical
Issues
Regular
Medications
Allergies
Blood
Type/Rhesus

IV. Flight Details (details can be submitted later through your Regional Chairpersons)

Arrival Flight
Number
Arrival Time
(based on GMT
+0800)
Arrival Terminal

Arrival Date
(DD/MM/YY)
Travel Insurance

Yes/No*

Terminal 1/Terminal 2/Terminal 3/Budget Terminal*

V. Job Preferences
1. Secretary
4. Accomodation &
transport

2. Treasurer
5. Cultural nightcultural fair
coordinator

3. Media
6. Utility & manpower

You should rank the jobs according to your capability and appeal to them, only choose 2 of them, it will
be your 1st and 2nd choice, 1 being the most interest and 2 being the least interest. Fill in the box
bellow, and tell us your reason

(1st choice)

(2nd choice)