NIRS-DOT Visiting Fellowship Program: Registration Form

Name:
Affiliation:
Address:
City:
State:
Country:
Zip:
Email:
Phone:
Fax:

Date

November 10 & 11, 2011

Course Fees

The fee for the program is $500. Course fees are refundable up to 30 days prior to the session.

Make checks payable to: Massachusetts General Hospital

Mail checks to:

Stacey Ladieu
Athinoula A. Martinos Center for Biomedical Imaging
149 Thirteenth Street - Room 2301
Charlestown, MA 02129

Please include YOUR NAME on the check.

Biosketch

Please include an informal statement describing your background (clinical, research, industrial, other). This biosketch will be distributed to the faculty and to other course participants. It should be no more than two paragraphs in length. Make the biosketch informal. It is intended to introduce you to the other participants and staff, not to apply for a job.

Questions? Contact sladieu@nmr.mgh.harvard.edu

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