Conference Registration Form
17TH ANNUAL MEETING
INTERNATIONAL SOCIETY FOR THE HISTORY OF THE NEUROSCIENCES
VENICE, ITALY - JUNE 19-23, 2012
All participants must complete and return this Registration Form
PERSONAL INFORMATION
Name 				_______________________________________________________________________________
Institution/Affiliation		_______________________________________________________________________________
Street address 			_______________________________________________________________________________
City, State/Province, Zip/Postal Code _______________________________________ 	      Country  _____________________________
Telephone 			___________________________________	Fax   ___________________________________
E-mail 				_______________________________________________________________________________
Name(s) of accompanying person(s) 	_______________________________________________________________________________

REGISTRATION FEES (U.S. Dollars or Euros) – Select one payment option:
□  PAYMENT  for  Option 1:  EURO – Bank Transfer
Please effect bank transfer as per instructions in the Announcement and Call for Abstracts (http://www.ishn.org/call2012.pdf)  

□  PAYMENT  for  Option 2:  US DOLLAR – Personal Check or Cashier’s Check or Money Order
Please send to the Treasurer of the ISHN a personal check or cashier’s check or money order in $US paid to the order of “ISHN”:
Dr. Joel Vilensky, Department of Medical Education, Indiana University School of Medicine, 2101 East Coliseum Blvd., Fort Wayne, IN 46805 USA
Email:   vilensk@ipfw.edu 		Fax :   001 260 481 6408

□  PAYMENT  for  Option 3:  EURO – Cash (on site)
Euro payment, in cash, at the Registration Desk on site at the meeting in Venice.

Registration Fees:  select payment in either US Dollars ($) or Euros (€ )
						OPTION 2				OPTION 1  or  OPTION 3
Full registration for ISHN members 			# ____ 	@ $____ 	= $ ____ 		# ____	@ €___ 	= € ____
Non-member Full registration				# ____ 	@ $____ 	= $ ____ 		# ____	@ €___ 	= € ____
Student (documentation required) Full registration		# ____ 	@ $____ 	= $ ____ 		# ____	@ €___ 	= € ____
Accompanying Person 				# ____ 	@ $____ 	= $ ____ 		# ____	@ €___ 	= € ____
One Day registration					# ____ 	@ $____ 	= $ ____ 		# ____	@ €___ 	= € ____

Banquet Dinner at Fondazione Giorgio Cini 		# ____	@ $ 80 	= $ ____ 		# ____	@ € 60 	= € ____

TOTAL  								   $ ____     			   € ____

Payment sent on (enter date): __________________   as per Option 1 or Option 2	

IN ORDER TO ASSIST THE PLANNING OF MEALS AND REFRESHMENTS, PLEASE INDICATE WHICH DAYS YOU INTEND TO ATTEND:
			Tuesday, June 19	Wednesday, June 20	  Thursday, June 21	Friday, June 22	Saturday, June 23
Yes / Attend	           □		       □	       □	     □		      □
No / Not Attend	           □		       □	       □	     □		      □

Please indicate any dietary restrictions (be specific about any food allergies or prohibitions) for Lunches and for the Banquet:
__________________________________________________________________________________________________________________

During the ISHN Meeting we are planning a Tour of Fondazione Cini.  If you would like to take part, please indicate:        YES □     NO □

SEND REGISTRATION FORM TO:    lorusso.lorenzo@gmail.com   or   rosetta.rosati@alice.it    and SEND A COPY TO:   doctorginn@gmail.com