Transcript Inschrijving voor de activiteiten ter ere van de Dies

Registration Form
131e Dies Natalis of L.P.S.V. „Aesculapius”
‘Ind(i)estructible‘ 2016
Registration for the activities in honor of the Dies Natalis
(Hand in to one of the members of the Dies committee or at ‘t Hok)
Date
Program
Description
Price
Monday 19
December
Reception
At ‘ALSV Quintus’
Free
Tuesday 20
December
Excursion
Biomedical Primate
Research Centre, Rijswijk
€ 1,00
Tuesday 20
December
Sports activity
Tikibad, Wassenaar
€ 10,00
Wednesday
21 December
Symposium (in Dutch)
‘An indestructible society
Free
through medicine: Making life
better?’ at Gorlaeus, lecture
room C1
Including lunch and drinks
afterwards
‘Suitable/Not Suitable ’ at “
de Hut van ome Henne”
€ 5,00
Wednesday
21 December
Theme party
Thursday 22
December
Cultural activity
Ballroom dancing at Dance
School ”Dance Fit”
€ 7,50
Friday 23
December
Gala
At “Brasserie de Poort”,
Leiden
€ 35,00
Friday 23
December
Dinner and gala
At “Brasserie de Poort”,
Leiden
€ 67,50
€ 3,50
Passe partout
€ 75,00
Gala (external)
€ 37,50
Dinner and gala
(external)
€ 75,00
Passe partout, dinner
and gala (external)
€ 150,00
Total amount
€
N.B. 1: External means not a member of „Aesculapius”.
Number
I have a passe partout, but I can not be present at the following activities:
................................................................................................................................
(Please opt out of an activity in a timely manner. If you don’t do that, it will have
consequences.)
Symposium lunch: vegetarian/allergies:
……………………………………………………………………………………………………………
Menu (by choice) dinner at Brasserie de Poort
Starter

Beef carpaccio

Mediterranean fish soup

Vegetarian
Main course

Wild Pepper (Stew pot)
with red cabbage

Salmon fillet
with mushrooms

Vegetarian
You
Partner
You
Partner
You
Partner
Dessert

Ice cream bombe
Allergies dinner (if any):.....................................................................................
...............................................................................................................................
Other particularities which the Dies committee must take into account:
..............................................................................................................................
Name: ..………………………………………………………………………………………………..
Name partner: ……………………………………………………………………………..
Signatory signs up for the 131e Dies Natalis der L.P.S.V. „Aesculapius”
‘Ind(i)estructible’, and authorizes the h.t. quaestor aesculapii, Jiry Boltjes, to
amortise once the amount owed of the bank account number below.
Registration closes at 9 December 2016; Registrations are binding.
Name:……………………………………………………………………………………………
Address:…………………………………………………………………………………………
Postal code, Residence:………………………………………………………….…………..
Telephone number:……………………………………………………………………………
Email:…………………………………………………………………………………………….
Total amount:…………………………………………………………………………………..
IBAN:………………………………………………………………………………………………
Domicile bank:…………………………………………………………………………………..
Date:……………………………………………………………………………………………….
Signature:
On behalf of the 131e Diescommissie ‘Ind(i)estructible’,
Bjorn Bouwer, Eline de Koning, Joep Feijen, Marije Otto, Bart Faas and Iris Vennis