REGISTRATION FORM FOR THE NATIONAL ADVOCACY WORKSHOP

Epilepsy Support Association Uganda (ESAU) will host a National Epilepsy Advocacy Workshop at the Hotel Africana on 28th November 2008. This workshop will bring together Stakeholders from district, regional referral hospitals, policy makers, NGOs etc. To participate in this workshop, every participant will need to be registered and sponsored. Kindly fill this form and return it to ESAU Secretariat. ESAU will get back to you to confirm your registration/accreditation. Self sponsored participants must accompany this form with a bank slip indicating they have paid 50,000/= (Fifty thousands shillings) to Epilepsy Support Association Mgt A/c 0140064263502 Stanbic Bank Corporate Branch.


First Name……………………………..		Last Name…………………………………..


Organization……………………………………………………………………………………….


Position in the organization………………………………………………………………………..

Address…………………………………………………………………………………………….


Tel: …………………………………… E-mail: …………………………………………………..

Why do you want to be sponsored? ..................................................................................................

……………………………………………………………………………………………………..

 
Fill in this form and return by post or e-mail to the undersigned who will get back to you to confirm your registration.


Deadline for registration is 15th November 2008.


Cissy Namakula
Administrative Assistant
Epilepsy Support Association Uganda
Plot 3, Ntinda 2 Road
P.O. Box 16260, Wandegeya Uganda
Tel:  0414  287700 Mob: 0772 450383
Email: esauganda@yahoo.com / info@epilepsy.org.ug