IMDSA's 2007 MDS RESEARCH & AWARENESS CONFERENCE
Reaching for Tomorrow!
Conference Registration Form

You can register at the conference. Please do not post this form, or make any payments in the form of paypal or sending of cheques. Please take this form with you and register at the conference itself. Thanks

Main Conference
IMDSA Member (membership dues must be current)
$65 Individual
$90 Family
IMDSA Non-Member (non-members will receive one year IMDSA membership)
$100 Individual
$140 Family

Youth Conference (ages 14 to Adult)
$30.00 to all attendees
$15.00 per each additional youth per family

Child Care (ages infant to 13)
$10.00 per child

Member Individual ___ Member Family ___ Non-Member Individual ___ Non-Member Family ___

Attendee's Name__________________________________________________

Additional Adults Name__________________________________________________

Additional Adults Name__________________________________________________

Mailing Address__________________________________________

City/State/Zip___________________________________________

Country________________________________________________

Phone Number___________________________________________

Email address____________________________________________

Research
I have a family member or am an individual with MDS & wish to participate in Research Yes ___No ___

Name of individual with MDS _______

Age of individual with MDS _______
(you will be contacted prior to the conference for a research appointment(s))

Saturday Evening Banquet (Per Plate)
Adult $30.00 X _______

Children ages 5-13 $16.00 X _______

Children 4 and under free X _______

Special Dietary Needs _______________________________________________________________________________________________________________

IMDSA's 2007 MDS RESEARCH & AWARENESS CONFERENCE
Reaching for Tomorrow!
Youth & Child Registration Form

Child Care (child care will be provided by Genetic and Therapy students for Saturday & Sunday only. Each child in child care will cost $5.00 to cover refreshments and activities)

Name & Age of child with MDS/Ds (please circle)

Name & Age of sibling in child care________________________________________________

Name & Age of sibling in child care ____________________________________________________

Name & Age of sibling in child care ____________________________________________________

Name & Age of sibling in child care _____________________________________________________

Youth Conference (ages 14 to Adult)
$30.00 to all attendees
$15.00 per each additional youth per family

Name & Age of youth with MDS/Ds (please circle)

Additional Youth's Name & Age __________________________________________________

Additional Youth's Name & Age __________________________________________________

Additional Youth's Name & Age __________________________________________________

Mailing Address ___________________________________________________

City/State/Zip ___________________________________________________

Country ____________________________________________

Phone Number ___________________________________________________

Email address ____________________________________________________

IMDSA is not responsible for any accident, illness, or injury incurred before, during or after the conference
weekend of June 29 – July 1, 2007.

By sending this application attendees agree to not hold IMDSA, its Board of Directors, or volunteers responsible for any incident incurred before, during or after the conference weekend of June 29-July 1, 2007.

All pictures taken throughout the conference weekend are the sole property of IMDSA. By sending this application below, or registering online, attendees agree to allow IMDSA to use any pictures taken throughout the weekend for any promotional or publicity purposes.

All Conference Registration fees are non-refundable.