Prefix Mr. Mrs. Ms. Dr. Prof.
First Name
Last Name
Suffix CPA D.D.S. D.M.D. D.V.M. Ed.D. Esq. II III IV Jr. M.D. Ph.D. R.N. R.N.C. Ret. Sr. USA USAF USAFR USAR USCG USMC USMCR USN USNR
Email
Address 1
Address 2
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Name of Institution or Affiliation
Current Position or Title
Department
Attending meeting as (check all that apply) CaregiverPatientGovernmentHealthcare ProviderIndustryNonprofitResearcherPayorOther
Do you or your loved one fall into one or more of these categories? (select all that apply) My child's mitochondrial disease has neurological issuesAs an affected adult, my diagnosis includes mitochondrial myopathyAs parent or caregiver of an affected adult, his/her diagnosis includes mitochondrial myopathyNone of the above
Do you plan on attending in person or remotely? In person Remotely Unsure
Please check if this is your first PFDD meeting Yes No
Dietary Restrictions (Kosher, vegetarian, allergies, etc.)
Special Needs (Wheelchair accessibility, hearing impaired, etc.)
Photo Consent Yes No Unsure We will be taking pictures and videos during the conference to include in future newsletters, on our website, and in literature promoting our mission. Do you give consent to use these photos?
Which nights will you be staying at the College Park Marriott? Thursday, March 28, 2019Friday, March 29, 2019I will not be staying overnight at the MarriottUnsure (UMDF has a special group rate for $159/night plus taxes)
Travel Scholarships Yes No Unsure UMDF will be providing a limited number of travel scholarships to patients/families (adults and adult caregivers with mitochondrial myopathies and parents/caregivers of children suffering neurologic manifestations in mitochondrial disease). Please indicate if you require a travel scholarship to attend.
Comments Is there anything we didn't ask that we should know about?
Comments