Registration Form
The 11th International Symposium of the
Asian and Pacific Parkinsonism Association (APPA)
Manila, Philippines ● March 13, 2016
Venue: Marriott Grand Ballroom CD, Level 2 at the Marriott Hotel Manila
Part 1: Participant Information
*Required Fields
*Person Living With Parkinson’s
Name: ___________________________________________________________________________________
Address: _________________________________________________________________________________
City: ________________________________Postal Code: ________________ State/Province: _____________
Country: _________________________________________ Telephone: _______________________________
E-mail: ________________________________________________________________________________
Emergency Contact Name: ______________________________________ Telephone: ___________________
*Partner/Carer/Other
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
City: ________________________________Postal Code: ________________ State/Province: _____________
Country: ___________________________________ Telephone: ____________________________________
E-mail: ___________________________________________________________________________________
Please check if you are: □ Partner/Carer
□ Other, Please specify__________________________________
*Special Requests
1.
2.
3.
4.
Do you have mobility restrictions?
Do you have any dietary restrictions?
Do you require wheelchair access?
Do you have any other special needs?
□ No
□ No
□ No
□ No
□ Yes, Please specify ___________________________
□ Yes, Please specify___________________________
□ Yes
□ Yes, Please specify____________________________
Part 2: Registration Fees
PLEASE CHECK THE REGISTRATION AMOUNT CORRESPONDING TO REGISTRATION TYPE
Registration prices (in USD)
Registrant
Single (Person Living With
Parkinson’s/Partner/Carer/Other)
Dual (Person Living With
Parkinson’s + Partner/Carer)
Registration prices (in PHP)
Registrant
Single (Person Living With
Parkinson’s/Partner/Carer/Other)
Dual (Person Living With
Parkinson’s + Partner/Carer)
Early Rate
On or before
February 25, 2016
Standard Rate
From February 26 –
March 13, 2016
○ $35 USD
○ $55 USD
○ $65 USD
○ $90 USD
Early Rate
On or before
February 25, 2016
Standard Rate
From February 26 –
March 13, 2016
○ 1,650 PHP
○ 2,600 PHP
○ 3,100 PHP
○ 4,300 PHP
Fees include: Refreshments and lunch and access to all sessions of the meeting.
Part 3: Payment
Return this form and payment to:
Makati Medical Center
C/o MS. JANE MARANAN
Neuroscience Department
Makati City, Philippines
Payment type:
Full payment of total registration fees must accompany this form. Your registration form may take up to two weeks to
process
____ CHEQUE made payable to the International Parkinson and Movement Disorder Society in US Dollars drawn out of
a US bank only
____ CREDIT CARD:
□ MasterCard
□ Visa
□ American Express
Name on Card: _____________________________________________
Card Number: ______________________________________________
Expiration Date:________________
Signature: _________________________________________________
CANCELLATION AND REFUND POLICY
Up to February 29, 2016: 100 % refund, minus a $25 administrative charge
From March 1 onwards: No refunds of registration fees
Should you wish to cancel, please contact the MDS International Secretariat: ssmith@movementdisorders.org.