INDONESIAN MEDICAL PHYSIOLOGY OLYMPIAD (IMPhO) 2019

FACULTY OF MEDICINE UNIVERSITAS AIRLANGGA

REGISTRATION FORM

Please complete the form below to register your participation in the IMPHO Unair 2019.

1. Full name of the university / college that you are representing:

Universitas Jenderal Soedirman

2. Your university / college logo (please attach if possible):

3. Team photo:
Please attach your team photo here (including any accompanying lecturer)
(Please match the names with the people in the photo).
4. The total number of delegates (A team consist of 3 students, and accompanying lecturer /
staff) joining the quiz.
Students: 3 Lecturer/ staff: 1

5. Please list the name (with title) of the accompanying lecturer/ staff:
T-Shirt size
No Name
(S/M/L/XL/XXL)
1 dr. Khusnul Muflikhah, MSc. L

6. Please list the full name of the students:

T-Shirt size
No Full Name Male/Female
(S/M/L/XL/XXL)
 1 Fiqham Muhamad Putra Male L

2 Abdurrahman Qaniturrazan Male M

3 Jarwati Female S

7. Additional Information of team leader

Name Phone number Email

Fiqham Muhamad Putra 082241953916 mfiqham@gmail.com

Sign

dr. Khusnul Muflikhah, MSc.