Registration form

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Meeting	National Lung Course 2025
Date	12-14 February 2025
Location	Hotel Heerlickheijd van Ermelo
Registration fee	€ 600,00 (€ 150,00 for members)

Title

Initials *

First name *

Infix

Last name *

Institute *

Department *

(Invoice) address *

Postal code *

City *

Country *

Phone *

Email address *

BIG registration number (if applicable)

Research activities *

Clinical research

Basic research

Both basic and clinical research

Other (please specify)

What is your current role? *

Start date of PhD trajectory (or enter N/A) *

Projected end date of PhD trajectory (or enter N/A) *

I am registered with the following graduate school (or enter N/A) *

Provide up to 5 keywords that best describe your research *

Dietary requirements

Hotel requirements *

I will need a single room (There will be a surcharge applied, see course description for amount)

I will share a room (You have the option to specify the name of your preferred roommate)

Full invoice address (street, number, postal code, city) *

Additional remarks

I hereby declare that I completed this form truthfully *

I have taken note of the privacy policy of Netherlands Respiratory Society and agree with the terms. *

Please complete this form and submit it before November 2, 2024

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