SLRI-CERN ASEAN Accelerator School

Synchrotron Light Research Institute (Public Organization)

Nakhon Ratchasima, Thailand
August 28 – September 1, 2017

ACCEPTANCE FORM

Please return IMMEDIATELY by email to Ms. Porntip Sudmuang

(porntip@slri.or.th)

Name : Dyah Ayu Daratika

Institute : Institut Teknologi Sepuluh Nopember, Indonesia

I WILL participate in the SLRI-CERN ASEAN Accelerator School 2017 [√]

on Introduction to Accelerator Physics.
I am fully aware that my participation is subsidized in part by the school [√]
organization and that complete assiduity to the entire scientific programme
is mandatory.

I am fully aware that I will be entirely on my own if I arrive before Sunday, [√]
August 27 or leave after Saturday, September 2, the school will neither
arrange for my accommodation nor will cover any cost associated to the
extended stay.

I am fully aware that any extra cost incurred during the stay (including [√]
private expenses at hotel, private transport costs, private meals, …) will not
be borne by the school organization.

I shall ensure that I have health and accident cover that includes adequate [√]
protection (including emergency medical treatment and hospitalization in
case of illness or accident) for the country in which the school takes place,
including cover against illness, accident, death and disability.

Date: 23 July 2017 Signature: Dyah Ayu Daratika