Welcome to the Faculty of Sports and Exercise Medicine

Individual Registration

Please enter information in the form below to process registration for event FSEM ASC - 17th September 2022.

Salutation *

First Name *

Last Name *

Email *

Irish Medical Council Number (If applicable)

Your Location (Hospital or County) *

Please tick the box option if you are happy for me to send on your details to Medcafe *

Payment Options *

Fellows & Members €150.00

Non Fellows & Members €170.00

Student Rate €50.00

Profession: (GP, Consultant, Nurse, Allied Healthcare Professional, Other). *

Profession If Other:

Amount

€

Payment Method

RCSI Credit Card Payments

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*