Association of West Indian Gastroenterologists

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Personal Details

Title
First Name
Initial
Last Name
Specialty
Day Phone
Evening Phone

Street
Line 2
City
State/Province
Country
ZIP
Email

Hotel Details

This room is for ONE person only.

This room is SHARED and Billed to ONE card holder (Multiple persons in Room, One Card)

Adults in Room			Children Over 12*
*Persons aged 12 and older are charged as adults. Children 11 and under stay free.

Primary Person: Details

Registration Fee

Arrival Date

(YYYY-MM-DD)

Departure Date

(YYYY-MM-DD)

2nd Person in Room: Details

Title

First Name

Last Name

Specialty*		EMAIL*
Country*		*Fields are required for Certificate of Attendance (If Required for Person 2)

Attendee Status

Arrival Date

(YYYY-MM-DD)

Departure Date

(YYYY-MM-DD)

3rd Person in Room: Details

Title

First Name

Last Name

Specialty*		EMAIL*
Country*		*Fields are required for Certificate of Attendance (If Required for Person 3)

Attendee Status

Arrival Date

(YYYY-MM-DD)

Departure Date

(YYYY-MM-DD)

Children 12 and Older in Room

Child #1 (Aged 12 and over)

Arrival Date

(YYYY-MM-DD)

Departure Date

(YYYY-MM-DD)

Child #2 (Aged 12 and over)

Arrival Date

(YYYY-MM-DD)

Departure Date

(YYYY-MM-DD)

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