DR.

SOETOMO REGIONAL PUBLIC HOSPITAL / FACULTY OF MEDICINE, AIRLANGGA

UNIVERSITY
Secretariat: Sport Clinic of Dr. Soetomo Regional Public Hospital / Faculty of Medicine, Airlangga
University
Mayjend Prof. Dr. Moestopo 6-8 Street, Surabaya, Telp. 031-5501430, fax 031-5026404

Number :37/Pan.Simposium - SC/IV/2019 Surabaya, April 16th 2019

Event :Request as Speaker
Attachment :1 (one) set

Dear.
Prof. Fumihiro Tajima, MD., Ph.D
In place

With Respect,
In connection with the event held by the Sport Clinic Development & Service Center
Dr Soetomo Regional Public Hospital on August 30 and 31 2019 on Campus A, Faculty
of Medicine, Airlangga University, Surabaya, with the theme "3rd National Sport
Science Meeting: 10-Year Experience in Comprehensive Management of Sport Clinic".
So with this, We request the willingness to be the Speaker at the event at:

Day / date : Saturday, August 31th, 2019

Hours : 09.10 - 09.30 (GMT +7)
Type : Satellite Symposium 2 Medical - Speaker
Title : Experience of Japan Paralympic Committee
Room : Anatomy Lecture Room 1 Faculty of Medicine, Airlangga
University

We send this request to be the Speaker at the event, for your willingness and
participation, we express our deepest gratitude.

Best regards,
Chair of the Development and Service Center Team
Sports Clinic

dr. Andre Triadi Desnantyo, Sp.OT(K)

NIP.19771216 200812 1 004
 DR. SOETOMO REGIONAL PUBLIC HOSPITAL / FACULTY OF MEDICINE, AIRLANGGA
UNIVERSITY
Secretariat: Sport Clinic of Dr. Soetomo Regional Public Hospital / Faculty of Medicine, Airlangga
University
Mayjend Prof. Dr. Moestopo 6-8 Street, Surabaya, Telp. 031-5501430, fax 031-5026404

Dear
Committee of “3rd National Sport Science Meeting : 10-Year Experience In
Comprehensive Management Of Sport Clinic”
Center for Sport Clinic Development and Services – Dr. Soetemo Regional Public Hospital

AVAILABILITY FORM
The undersigned below:

Name : __________________________________________________________

Institutional Address : __________________________________________________________

Telephone : __________________________________________________________

Cellphone/WA Number: _________________________________________________________

Email : __________________________________________________________

I. Available/ Not Available*) to be a Speaker at Satellite Symposium (1) Medical, entitled:

Experience of Japan Paralympic Committee
II. Available/ Not Available*) to send a Curriculum Vitae (CV) with a maximum limit of 31
May 2019
III. Available/ Not Available*) to send material in the form of PPT with a maximum limit of
29 August 2019
IV. Availabke/ Not Available*) to confirm file delivery to cellphone / WA number:
081216904186 (Zahra), email: sportclinicsby@yahoo.com
V. Available/ Not Available*) allows the committee to copy the material to the participants

_________________________, __________________ 2019

Approved by:
,

Prof. Fumihiro Tajima, MD., Ph.D

*cross the unnecessary ones

 DR. SOETOMO REGIONAL PUBLIC HOSPITAL / FACULTY OF MEDICINE, AIRLANGGA
UNIVERSITY
Secretariat: Sport Clinic of Dr. Soetomo Regional Public Hospital / Faculty of Medicine, Airlangga
University
Mayjend Prof. Dr. Moestopo 6-8 Street, Surabaya, Telp. 031-5501430, fax 031-5026404

Number :38/Pan.Simposium - SC/IV/2019 Surabaya, April 16th 2019

Event :Request as Speaker
Attachment :1 (one) set

Dear.
Yasunori Umemoto, MD., Ph.D
In Place

With Respect,
In connection with the event held by the Sport Clinic Development & Service Center
Dr Soetomo Regional Public Hospital on August 30 and 31 2019 on Campus A, Faculty
of Medicine, Airlangga University, Surabaya, with the theme "3rd National Sport
Science Meeting: 10-Year Experience in Comprehensive Management of Sport Clinic".
So with this, We request the willingness to be the Speaker at the event at:

Day/ date : Friday, August 30th 2019

Hours : 12.30 – 12.50 (GMT +7)
Type : Satellite Symposium (Session 1) – Speaker
Title : Overuse Shoulder, What are The Predictors Could Be Prevented
Room : Anatomy Lecture Room 1 Faculty of Medicine, Airlangga
University

Day / date : Saturday, August 31th, 2019

Hours : 11.30 -12.30 (GMT +7)
Type : Satellite Symposium 2 Medical - Speaker
Title : Prosthetic for sport
Room : Anatomy Lecture Room 1 Faculty of Medicine, Airlangga
University

We send this request to be the Speaker at the event, for your willingness and
participation, we express our deepest gratitude.

Best regards,
Chair of the Development and Service Center Team
Sports Clinic

dr. Andre Triadi Desnantyo, Sp.OT(K)

NIP.19771216 200812 1 004
 DR. SOETOMO REGIONAL PUBLIC HOSPITAL / FACULTY OF MEDICINE, AIRLANGGA
UNIVERSITY
Secretariat: Sport Clinic of Dr. Soetomo Regional Public Hospital / Faculty of Medicine, Airlangga
University
Mayjend Prof. Dr. Moestopo 6-8 Street, Surabaya, Telp. 031-5501430, fax 031-5026404

Dear
Committee of “3rd National Sport Science Meeting : 10-Year Experience In Comprehensive
Management Of Sport Clinic”
Center for Sport Clinic Development and Services – Dr. Soetemo Regional Public Hospital
AVAILABILITY FORM
The undersigned below:

Name : __________________________________________________________

Institutional Address : __________________________________________________________

Telephone : __________________________________________________________

Cellphone/WA Number: _________________________________________________________

Email : __________________________________________________________

I. Available/ Not Available*) to be a speaker at Satellite Symposium (Session 1), entitled:

Overuse Shoulder, What are The Predictors Could Be Prevented
II. Available/ Not Available *) to be a speaker at Satellite Symposium (2) Medical entitled:
Prosthetic for Sport
III. Available/ Not Available *) to send a Curriculum Vitae (CV) with a maximum limit of 31
May 2019
IV. Available/ Not Available *) to send material in the form of PPT with a maximum limit of
29 August 2019
V. Available/ Not Available *) to confirm file delivery to cellphone / WA number:
081216904186 (Zahra), email: sportclinicsby@yahoo.com
VI. Available/ Not Available *) allows the committee to copy the material to the participants
_________________________, __________________ 2019

Approved by:

Yasunori Umemoto, MD., Ph.D

*cross the unnecessary ones

 DR. SOETOMO REGIONAL PUBLIC HOSPITAL / FACULTY OF MEDICINE, AIRLANGGA
UNIVERSITY
Secretariat: Sport Clinic of Dr. Soetomo Regional Public Hospital / Faculty of Medicine, Airlangga
University
Mayjend Prof. Dr. Moestopo 6-8 Street, Surabaya, Telp. 031-5501430, fax 031-5026404

Number :39/Pan.Simposium - SC/IV/2019 Surabaya, April 16th 2019

Event :Request as Speaker
Attachment :1 (one) set

Dear.
Yukio Mikami, MD, Ph.D
In Place

With Respect,
In connection with the event held by the Sport Clinic Development & Service Center
Dr Soetomo Regional Public Hospital on August 30 and 31 2019 on Campus A, Faculty
of Medicine, Airlangga University, Surabaya, with the theme "3rd National Sport
Science Meeting: 10-Year Experience in Comprehensive Management of Sport Clinic".
So with this, We request the willingness to be the Speaker at the event at:

Hari/tanggal : Saturday, August 31th 2019

Jam : 08.20 – 08.40 (GMT +7)
Jenis : Plenary Symposium Medical – Speaker
Judul : Cardiorespiration Endurance Exercise for increase Athlete's
Performance
Ruang : Hall A, Medical Faculty, Airlangga University

We send this request to be the Speaker at the event, for your willingness and
participation, we express our deepest gratitude.

Best regards,
Chair of the Development and Service Center Team
Sports Clinic

dr. Andre Triadi Desnantyo, Sp.OT(K)

NIP.19771216 200812 1 004
 DR. SOETOMO REGIONAL PUBLIC HOSPITAL / FACULTY OF MEDICINE, AIRLANGGA
UNIVERSITY
Secretariat: Sport Clinic of Dr. Soetomo Regional Public Hospital / Faculty of Medicine, Airlangga
University
Mayjend Prof. Dr. Moestopo 6-8 Street, Surabaya, Telp. 031-5501430, fax 031-5026404

Dear
Committee of “3rd National Sport Science Meeting : 10-Year Experience In
Comprehensive Management Of Sport Clinic”
Center for Sport Clinic Development and Services – Dr. Soetemo Regional Public Hospital

AVAILABILITY FORM
The undersigned below:

Name : __________________________________________________________

Institutional Address : __________________________________________________________

Telephone : __________________________________________________________

Cellphone/WA Number: _________________________________________________________

Email : __________________________________________________________

I. Available/ Not Available*) to be a speaker at Plenary Symposium Medical,

entitled: Cardiorespiration Endurance Exercise for increase Athlete's Performance
II. Available/ Not Available*) to send a Curriculum Vitae (CV) with a maximum
limit of 31 May 2019
III. Available/ Not Available*) to send material in the form of PPT with a maximum
limit of 29 August 2019
IV. Availabke/ Not Available*) to confirm file delivery to cellphone / WA number:
081216904186 (Zahra), email: sportclinicsby@yahoo.com
V. Available/ Not Available*) allows the committee to copy the material to the
participants

_________________________, __________________ 2019

Approved by,

Yukio Mikami, MD, Ph.D

*cross the unnecessary ones