UCL INSTITUTE OF NEUROLOGY
QUEEN SQUARE
LONDON WC1N 3BG
REGISTRATION FORM
EMRI Erasmus Course on Magnetic Resonance Imaging
Central Nervous System I
London (UK), 8-12 June 2015 (five days)
Please complete and return this form by email to:
Email: skaaro3@ucl.ac.uk
Payment via online booking must be made before your place is confirmed:
http://onlinestore.ucl.ac.uk/browse/extra_info.asp?compid=1&modid=2&deptid=125&catid=178&pr
odid=883
a) PLEASE WRITE IN CAPITAL LETTERS:
Forenames ……………………………………………..
Surname ………………………………………………….
Full postal address ……………………………………………………………………………………………..........
…………………………………………………………………………………………………………………………..
Telephone/Mobile ……………………………………Email …………………………………………………………
b) PLEASE TICK APPROPRIATE BOX:
Registration Fees: (fee includes Lectures, Workshop & Dinners)
☐
Certified Radiologist
£550 for full course (5 days)
Radiologists in training
£450 for full course (5 days) ☐
Payment via online booking must be made before your place is confirmed:
http://onlinestore.ucl.ac.uk/browse/extra_info.asp?compid=1&modid=2&deptid
=125&catid=178&prodid=883
UCL Institute of Neurology  National Hospital for Neurology & Neurosurgery  Queen Square  London WC1N 3BG
 +44 (0)20 7692 2362  Fax: +44 (0)20 7278 5069  http://www.ucl.ac.uk/ion/
Director: Professor Michael G Hanna BSc(Hons) MBChB(Hons) MD FRCP(UK)
Institute Secretary: R P Walker BSc (Econ)
The Institute of Neurology promotes teaching and research of the highest quality in neurology and the neurosciences.