Registration Form

Email for non-humans

Tickets

Total (€)

Payment Status

Select your ticket *

Full Package (Pestana Palace)
Full Package (Hyatt regency)
Pestana Palace (Price per night)
Hyatt Regency (Price per night)
Lunch (Price per meal)
Gala Dinner
Registration
Registration (Reduced price for residents)

Full Package (Pestana Palace) - Quantity *

Full Package (Hyatt regency) - Quantity *

Pestana Palace - Quantity *

Hyatt Regency - Quantity *

Lunch - Quantity *

Gala Dinner - Quantity *

Registration - Quantity *

Details

Full Package (Pestana Palace)

Full Package (Pestana Palace) #1

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Full Package (Pestana Palace) #2

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Full Package (Pestana Palace) #3

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Full Package (Pestana Palace) #4

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Full Package (Pestana Palace) #5

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Full Package (Hyatt regency)

Full Package (Hyatt regency) #1

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Full Package (Hyatt regency) #2

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Full Package (Hyatt regency) #3

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Full Package (Hyatt regency) #4

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Full Package (Hyatt regency) #5

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Pestana Palace (Price per night)

Pestana Palace (Price per night) #1

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

How many nights will you be staying? *

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Pestana Palace (Price per night) #2

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

How many nights will you be staying? *

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Pestana Palace (Price per night) #3

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

How many nights will you be staying? *

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Pestana Palace (Price per night) #4

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

How many nights will you be staying? *

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Pestana Palace (Price per night) #5

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

How many nights will you be staying? *

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Hyatt Regency (Price per night)

Hyatt Regency (Price per night) #1

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

How many nights will you be staying? *

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Hyatt Regency (Price per night) #2

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

How many nights will you be staying? *

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Hyatt Regency (Price per night) #3

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

How many nights will you be staying? *

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Hyatt Regency (Price per night) #4

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

How many nights will you be staying? *

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Hyatt Regency (Price per night) #5

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

How many nights will you be staying? *

What date will you be arriving? *

What date will you be departing? *

Will you be accompanied?

The reservation is based on a single use, all requests for double bedding will be considered as extra and paid at your checking out.

Lunch (Price per meal)

Lunch (Price per meal) #1

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Choose your meal(s) *

Dinner Thursday 23
Lunch Friday 24
Lunch Saturday 25

Are you vegetarian? *

Any allergies or dietary restrictions? *

Lunch (Price per meal) #2

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Choose your meal(s) *

Dinner Thursday 23
Lunch Friday 24
Lunch Saturday 25

Are you vegetarian? *

Any allergies or dietary restrictions? *

Lunch (Price per meal) #3

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Choose your meal(s) *

Dinner Thursday 23
Lunch Friday 24
Lunch Saturday 25

Are you vegetarian? *

Any allergies or dietary restrictions? *

Lunch (Price per meal) #4

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Choose your meal(s) *

Dinner Thursday 23
Lunch Friday 24
Lunch Saturday 25

Are you vegetarian? *

Any allergies or dietary restrictions? *

Lunch (Price per meal) #5

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Choose your meal(s) *

Dinner Thursday 23
Lunch Friday 24
Lunch Saturday 25

Are you vegetarian? *

Any allergies or dietary restrictions? *

Gala Dinner

Gala Dinner #1

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Are you vegetarian? *

Any allergies or dietary restrictions? *

Gala Dinner #2

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Are you vegetarian? *

Any allergies or dietary restrictions? *

Gala Dinner #3

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Are you vegetarian? *

Any allergies or dietary restrictions? *

Gala Dinner #4

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Are you vegetarian? *

Any allergies or dietary restrictions? *

Gala Dinner #5

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Are you vegetarian? *

Any allergies or dietary restrictions? *

Registration

Registration #1

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Registration #2

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Registration #3

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Registration #4

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Registration #5

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Registration (Reduced price for residents)

Registration (Reduced price for residents) #1

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Registration (Reduced price for residents) #2

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Registration (Reduced price for residents) #3

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Registration (Reduced price for residents) #4

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Registration (Reduced price for residents) #5

Name *

First Name

Last Name

Email Address *

What is your title? *

MD
DO
Other

Are you a Resident or Fellow? *

Resident
Fellow
N/A

Business Address

Street Address *

Address Line 2 *

City *

State / Province / Region

ZIP / Postal Code *

Country *

Phone Number

Save The Date

Download Postcard

Registration Form

2900 Lake Viste Drive
Suite 200
Lewisville, TX 75067
UNITED STATES

2 Allée Jacques Frimot
35000 Rennes
FRANCE

Tel : +33 2 99 33 86 50

Registration Form

2900 Lake Viste Drive Suite 200 Lewisville, TX 75067 UNITED STATES

2 Allée Jacques Frimot 35000 Rennes FRANCE

Tel : +33 2 99 33 86 50

2900 Lake Viste Drive
Suite 200
Lewisville, TX 75067
UNITED STATES

2 Allée Jacques Frimot
35000 Rennes
FRANCE