Conference Online Registration Form

Full Name*

First NameLast Name

Area/field of work/expertise*

Address*

Street Address

Street Address Line 2

City

Country

Your place of work

E-mail*

example@example.com

Phone Number*

Area CodePhone Number

First time to attend RPA Annual conference?*

YesNo

I will attend:

Event 1 - Date of Event 1Event 2 - Date of Event 2

What's your T-Shirt size?*

Registration Fee*

Active member RPARPA member who ALREADY paid annual RPA membership fees

FreeRWF

PediatricianPediatricians who DIDN'T pay annual RPA membership fees

60,000RWF # of Participants

Nurse, and other allied professionals (lab technicians, nutritionists, pharmacists, radiology technicians)

15,000RWF Quantity

Resident

20,000RWF Quantity

Medical student

10,000RWF Quantity

Others

45,000RWF Quantity

General Practitioner

20,000RWF Quantity

Total

0RWF

Proof of Payment (Bank Deposit Slip): Pay at this account : GT Bank : account 211 130460 1 5101 2, Association Rwandaise de Pediatrie or Pay using MoMo at this code*182*8*007495# and provide the scanned payment proof*

Attach the bank deposit slip (Bordereau) here (file type: pdf, jpg, jpeg, png)

RPA 7th Annual Conference Online Registration