Registration for MODULE I-VII

Name

Dieses Feld dient zur Validierung und sollte nicht verändert werden.

Gender*

Surname*

First name*

Date of birth*

Email*

Academic Title(s)

Specialty*

Hospital / Academic Center / Institution / Company*

Position / Function*

Contact Address*

Mobile Phone*

Your setting is (please tick what describes it best)*

If other, please specify

Further comments on your current and future professional activities/career (optional)

Have you already participated in any VSCR or SFU training?*

If yes, please specify in which one and when

Declaration - Data protection*

o Yes, I accept that the personal data I have provided above will be processed for organizational and administrative purposes. I also accept that my name and address information will be communicated to fellow students, teaching staff and persons responsible for academic services. I agree that my name and photograph material in which I appear may be used for VSCR-SFU marketing activities. I may at any time withdraw this consent by giving notice in writing to the program director. If I join, I agree to attend the course to the dedicated time (monthly) and to complete the exercises in order to gain a certificate.
Upon submission of the application form, I agree that the application form becomes binding. By submitting this form, I confirm the accuracy and completeness of my statements.

VSCR Health Economics and Outcomes Research Diploma (HEOR) Program for Sub-Saharan Africa