Learner registration

Supervision clinique 2025 - Massamba M'BAYE - from December 1, 2025 to December 2, 2025

Vous pouvez vous préinscrire ou préinscrire un de vos apprenants à la formation grâce à ce formulaire.
Merci de rentrer un maximum d'informations pour simplifier le travail d'enregistrement.
Vous pouvez laisser un message complémentaire dans la partie “Notes libres”.

General information

Honorific

First name*

Last name* Email* Date of birth*

Birth name

Nationality

City of birth*

Postcode of place of birth

Address*

Postcode*

City*

Country*

Phone

Language in the Learners' Portal

Status

Profession*

Company registration number

DPC fields

ADELI NO.

RPPS NO.

Main exercise (> 50%)*

Other

Free notes

Fields marked with * are mandatory.

The data collected in this form is processed by SYNETIC Formation in order to manage your registration on the site. To find out more about the management of your personal data and to exercise your rights, we invite you to read our privacy policy