Registration Form
Fill out the form carefully for registration
Personal Information
Name
*
First Name
Middle Name
Last Name
Nickname
Title
Please Select
Mr.
Ms.
Dr.
School
*
Please Select
Angeles University Foundation - School of Medicine
Cagayan State University - College of Medicine and Surgery
La Consolacion University Philippines - College of Medicine
Lyceum Northwestern University - Dr. Francisco Q. Duque Medical Foundation
Mariano Marcos State University - College of Medicine
Saint Louis University - School of Medicine
St. Paul University Philippines - College of Medicine
University of Northern Philippines - College of Medicine
Virgen Milagrosa University - College of Medicine
Year Level
Please Select
I
II
III
IV
Mobile Number
*
Format: (0000) 000-0000.
Alternative Mobile Number
Format: (0000) 000-0000.
E-mail Address
*
Health Information
Food Restriction/Allergies
*
Any personal health issues/concerns?
*
Events
Academics
Asclepius Debate Tournament
Medical Quiz Bee
Clinico-Pathologic Case Conference
Medical Student Research Competition
None
Cultural
MedGroove
Medrhythmia
Mr. & Ms. APMC-SN Luzon 2019
None
Sports
Volleyball
Basketball
Table Tennis
Badminton
Athletics
Chess
Scrabble
None
Registration fee
*
4500 (with accommodation)
3000 (without accommodation)
In case of emergency
Person to Contact
*
Relationship
Phone Number
*
Format: (0000) 000-0000.
Shirt Size
*
Please Select
XS
S
M
L
XL
2XL
Expectations for the Regional Convention
Submit
Should be Empty: