CATHCHAT Workshop Registration Form

Interventional Cardiac Catheterisation Workshop

Red Cross Children’s Hospital, Cape Town, 14-17 March 2017
Registration Form

Please fill in the form below.
Name*

PrefixFirst NameLast Name
Phone Number*

Area CodePhone Number
Your affiliations

Hospital Name

University Name

CityState / Province

Country
E-mail*
Please pay the registration fee of R1500.00 to:

The Children’s Hospital Trust

Standard Bank Rondebosch branch

Bank a/c: 071433090

Branch no: 02500911

Swift address: SBZAZAJJ

Email proof of payment to: Natasha.rossouw@chtrust.org.za

Please use CATHCHAT and your SURNAME as reference

Or Fax to: (27) 021 401 3071

Tel no: (27) 021 686 7860
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Interventional Cardiac Catheterisation Workshop