Registration Form
Contact Information (*must fill)
*Name:
(First Name)
( Dr.  Prof.)
(Last Name)
*Position:
Specialty:
*Department:
*Hospital:
Correspondence Address:
Phone:
Fax:
*E-mail:
*Do you want to join OLC membership to receive notification of upcoming workshops? Yes No
*Applied sponsorship for this program? Yes: __________________ No
Particulars
No. of years in Orthopaedics:
HOT / BST: Year
(if applicable)
Other specialist qualification, e.g. FRCS:
(if applicable)
Why are you interested in this course?
What are your learning objectives/expectations?
Payment
Please mail your completed registration form together with a cheque payable to “The Chinese University of Hong Kong”
to Orthopaedic Learning Centre,1/F Li Ka Shing Specialist Clinics, North Wing, Prince of Wales Hospital, Shatin, Hong
Kong. Please send the form to us by email to [email protected] if you are paying by credit card.
Please complete Credit Card Payment Authorization below if you are using
credit card payment.
Credit Card Payment of Registration Fee
I hereby authorize the Chinese University of Hong Kong to debit the following credit card in the total
amount indicated below for payment of the registration fee for the above-mentioned person(s).
Paying Cardholder Name:
(As shown on card)
Paying Card Number:
Expiry Date:

VISA

MasterCard
 Hands-on  Observer
Total Amount to be Debited: HK$/ US$
Paying Cardholder Contact:
Date:
Tel.: (
)
Fax: (
)
Page 1 of 2 (PTO)
Please provide the details of your experience in order to
offer the most optimal grouping to facilitate your needs.
Sub-specialty
Years of experience (please circle the correct ones)
Hip
0
1-2
3-4
5-9
10+
20+
Knee
0
1-2
3-4
5-9
10+
20+
Spine
0
1-2
3-4
5-9
10+
20+
Trauma
0
1-2
3-4
5-9
10+
20+
Shoulder
0
1-2
3-4
5-9
10+
20+
Elbow
0
1-2
3-4
5-9
10+
20+
Hand/Wrist
0
1-2
3-4
5-9
10+
20+
Arthroscopy
0
1-2
3-4
5-9
10+
20+
Sports Medicine
0
1-2
3-4
5-9
10+
20+
Cranio-maxillofacial
0
1-2
3-4
5-9
10+
20+
Pediatrics
0
1-2
3-4
5-9
10+
20+
Others
0
1-2
3-4
5-9
10+
20+
Skills and volume (e.g. 100 cemented hips per year)
Page 2 of 2