The 2nd Gerry Schwartz and Heather Reisman International Congress on
Chronic Disorders & Disabilities in Children
Regency Jerusalem Hotel, Jerusalem - December 3-4, 2008,
REGISTRATION & ACCOMMODATION FORM for Israeli Participants
Please type or write in capital Letters and send by e-mail or fax to:
International Travel and Congresses
82 Menachem Begin St., Tel-Aviv 67138
Tel. 972-3-7610813/4/6/ 972-3-7610792, Fax. 972-3-7610791
e-mail: elisheva@internationaltc.co.il
PERSONAL CONTACT INFORMATION
Title: _________________ Prof. Dr. Ms. Mr.
Surname ____________________ First Name ______________________
Institution: __________________________
Residence : _________________________
Mailing Address: ____________________________________________________________________________________
City _______________ State/Pro _____________ Zip Code _______
Telephone (Working Hours) _______________ Fax_____________ Telephone (Home)_____________________
Email address: _______________________________________________________________
REGISTRATION - Kindly mark the appropriate checkbox
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From November 1st 2008 |
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One day registration |
NIS 100 |
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Two days registration |
NIS 150 |
ACCOMMODATION - Kindly mark the appropriate checkbox
PLEASE NOTE THAT THE FOLLOWING ROOM RATES ARE AVAILABLE FOR THE DATES OF THE
CONGRESS (DECEMBER 3 & 4, 2008)
Please make the following reservation
Single room/ Double room * sharing with ________________________ (mandatory field in order to
book a double room)
Check in date:_____/_______/_____ Check out date: ______/______/ ______ Total nights: _____________________
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Single Room on
Bed & Breakfast Basis
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NIS 520 per room per night
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Single Room on
Half Board Basis
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NIS 690 per room per night
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Double Room on
Bed & Breakfast Basis
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NIS 610 per room per night
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Double Room on
Half Board Basis
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NIS 805 per room per night |
PAYMENT METHOD
Enclosed is cheque No.__________ for the amount of NIS - payable
to: International Travel and Congresses
Enclosed is a copy of my bank transfer for the amount of NIS
_______ or equivalent - payable to: International Travel andCongresses, Otsar Hahayal Bank (14), Branch No. 357, Account No.38215 / IBAN IL11-0143-5700-0000-0013-603 / Swift: OTSHILIT (Please ensure that your name appears on the bank transfer).
Please charge the amount of NIS _________ to my credit card:
Mastercard
Diners Club
Visa
American Express
Credit Card Number____________________ Expiration date ____________
Name of Card Holder______________
Registration forms without payment information will not be accepted.
- I accept the Congress Registration and Hotel Reservation Cancellation Policy as follows:
Faxed, electronically mailed or post-marked:
Cancellation received prior to November 25, 2008 - full refund less 25%. No refund for cancellations received after this date.
Signature _________________ Date__________________________
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