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Collaborative Innovation for the Future of Health

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Last name*
E-mail*
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Address*
Postal code*
City*
Country*

Invoice details

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VAT
PO number (if any)

<li>
								<div class="row title">
									<div class="columns small-12 medium-12 large-6">
										<strong>Participant</strong>
									</div>
									<div class="columns small-12 medium-12 large-6 text-right">
										<a class="remove-event-participant"><i class="fa fa-user-slash"></i> remove participant</a>
									</div>
								</div>
								<div class="row">
									<div class="columns small-12 medium-12 large-6">
										<label>First name<span class="req">*</span></label>
										<input name="participants[fname][]" type="text" value="" />
										<br />
										<label>Last name<span class="req">*</span></label>
										<input name="participants[lname][]" type="text" value="" />
										<br />
										<label>Function</label>
										<input name="participants[function][]" type="text" value="" />
										<br />
										<label>E-mail<span class="req">*</span></label>
										<input name="participants[email][]" type="text" value="" />
										<br />
									</div>
									<div class="columns small-12 medium-12 large-6">
										
											<label>Category<span class="req">*</span></label>
											<select name="participants[category][]" style="width: 100%;">
											
												<option value="BJA Member - Attending the event at imec">&euro; 30.00 -- BJA Member - Attending the event at imec</option>
												
												<option value="BJA Member - Attending the event digitally">&euro; 0.00 -- BJA Member - Attending the event digitally</option>
												
												<option value="Non-Member - Attending the event at imec">&euro; 50.00 -- Non-Member - Attending the event at imec</option>
												
												<option value="Non-Member - Attending the event digitally">&euro; 0.00 -- Non-Member - Attending the event digitally</option>
												
												<option value="Leuven MindGate member - Attending the event at imec">&euro; 30.00 -- Leuven MindGate member - Attending the event at imec</option>
												
											</select>
											<br />
											
											<label class="small-line-height">BJA Member (YES/NO)<span class="req">*</span></label>
											<textarea name="participants[subs_custom_field_01][]" rows="4"></textarea>
											<br />
											
									</div>
								</div>
							</li>

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