4th International Fascia Research Congress

Workshop Proposal Submission Form

Please submit your proposal following the workshop criteria.

* indicates required field
SECTION 1: PRESENTER INFORMATION
First Name*
Last Name*
Title (e.g., PhD, MD, DC)
Position/Institution*
Email*
Re-enter Email*
Address 1
Address 2
City/Town
State/Province (Canadian provinces follow US states)
Postal/Zip Code
Country
Home Phone
Business Phone

SECTION 2: WORKSHOP PROPOSAL INFORMATION
Title of Workshop *
Workshop Format * Half Day Full Day
Attach Workshop Proposal *
(Click the "browse" or "choose file" button, locate your proposal, click "open".)

  Reminder: only MS Word or PDF formats will be accepted
Comments
Replace Prior Proposal? * No Yes
Check 'Yes' for any workshop proposal you previously submitted to be replaced by this one. Checking 'Yes' means that all prior submissions will be removed.

DISCLOSURE SECTION A
Will your presentation include discussion of any commercial products or services?* No Yes
If Yes, please list the manufacturer(s) or provider(s) and describe the nature of the relationship(s):

DISCLOSURE SECTION B
Is the information in this presentation supported by a grant from a commercial supporter(s)? * No Yes
If Yes, please list the relevant commercial supporter(s) and describe the nature of the relationship(s):

* I understand that the 2015 Fascia Congress Scientific Review Committee has the final determination for accepted workshops. I agree that 2015 Fascia Congress organizers reserve the right to accept, reject or amend any or all proposals. I understand that I will be required to register for the conference if my workshop proposal is accepted.
 


Questions or difficulty using this form? Contact us at: info@fasciacongress.org.