Registration Fees (In Thai Baht)* Early-Bird Registration Only Till 31St October 2017

The 16th ASCoN Conference and Workshop 7th-10th December 2017 At the UNISERV, Chiang Mai University, Chiang Mai, Thailand Registration Form (Please type and insert √ in front of the appropriate choices) Title and First name Middle name Surname/Last name

Professional Other Working place/affiliation

 Rehab physician  Rehab Resident  Specialist in………………………………  Master/Ph.D. student in  Nurse ……………………………………   Physiotherapist Undergrad student …………   Occupational therapist SCI consumer   Social worker Accompanying person   Psychologist Other …………………… E-mail address:

Conference and Workshop Conference only I would like to register for Workshop* 7-10 Dec only* 7 Dec 8-10 Dec Early-bird registration Early-bird Early-bird Late/on site  ASCoN member only Registration only registration registration 3,500 800 4,000 5,000 -  All professionals 3,000 600 3,500 4,000 -  Student, resident in-training  SCI consumers 3,000 600 3,500 4,000  Accompanying of SCI consumer# 3,000 600 3,500 4,000  Non-ASCoN member 4,500 1,000 5,000 6,000 Registration fees (in Thai Baht)* Early-bird registration only – till 31st October 2017 I have paid ……………… Baht via Bank (name)………………………….. Transferred on (date) ………………………… To bank account name: Workshop on SCI management. Account number: 566-270281-0 Siam Commercial Bank Public Company Limited Swift code: SICOTHBK Please scan the bank document and send it along with the registration fee

Attached  The bank document for the transferred registration fee document(s)  An abstract of my presentation  A reference letter (for resident in training/student)  None Special request  No  Vegetarian foods  Universal design toilet and ramp  Other ………………………………………………. Signature Date of submission

Please scan and send it to [email protected] The 16th ASCoN Conference and Workshop 7th-10th December 2017 At the UNISERV, Chiang Mai University, Chiang Mai, Thailand Abstract Form for Research Study, Free Paper and Poster (Please type and insert √ in front of the appropriate choices) Title and First name Middle name Surname/Last name

Preferred  Oral presentation  ASCoN research contest presentation  Poster presentation  ASCoN structured poster contest  Both Attached is/are  An abstract of my presentation  A reference letter (for resident in training/student) Title:

Authors: (underline the presenter’s name)

Affiliation (in short): Objectives:

Methods:

Results:

Conclusion:

Note: Not more than 300 words. Deadline for submission: 30th September 2017 Please scan and send it to [email protected] The 16th ASCoN Conference and Workshop 7th-10th December 2017 At the UNISERV, Chiang Mai University, Chiang Mai, Thailand Abstract Form for Interesting Clinical Issues/Voice of customer Title and First name Middle name Surname/Last name

Preferred  Oral presentation  Interesting clinical issue presentation  Poster presentation  Voice of customer  Both Title:

Authors: (underline presenter’s name)

Affiliation (in short): Objectives:

Clinical/interesting issues:

Conclusion:

Note: Not more than 300 words. Deadline for submission: 30th September 2017 Please scan and send it to [email protected]