Registration form for the 6th PAIP scientific conference

I declare participation in the 6th PAIP scientific conference Psychotherapy – practice, science, passion on 13 – 15th January 2012 in Cracow.

Attention: the following form relates to presence on the conference only.
To submit a presentation please fill in the presentation submission form.

Fields marked with * are required.

* Name:
* Scientifical degree:
* Address - street, number:
* Post code, city:
Country:
* E-mail address:
Telephone:
Professional title in psychotherapy:
Job/position:
Parent psychotherapy association:
I need accomodation in Polish Institute for Integrative Psychotherapy:
Scientific exchange mailing list In order to facilitate future contact and exchange between the conference participants we are creating the scientific exchange mailing list. If you tick the following field and fill the form, your data will be made accessible to other conference participants. The list will include your name, e – mail address, scientific degree, professional title in psychotherapy, position, parent psychotherapy organisation and data from the fields marked with *.
I want to figure on the mailing list:
Afiliations*:
I am looking for partners for scientific research cooperation*:
Scientific interests (please state briefly)*:
Please refer patients to me*:
Contact (e – mail or phone number) patients can be referred to*:
Location of the practice*:
‘Specialisation’ in psychotherapy. Please state (i.e. age, type of disorders)*:
I want to receive information about psychotherapy training and conferences:
Other demands or comments*:
According to the Personal Data Protection Act submitting the following declaration means accepting quoted data to be stored and processed for the purposes of the 6th PAIP scientific conference.
Code (case does not match)
Type the code: