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

DSA Board Member Conference Registration Form

Only ONE DSA board member per DSA will be allowed ONE free individual registration. If the DSA board member plans to bring along family, friends or other DSA board members please fill out our other registration form in addition to this one.

Board Members Name ______________________________________________________________

Board Members Position____________________________________________________________

Board Members Email______________________________________________________________

DSA Name_______________________________________________________________

DSA Address_____________________________________________________________

DSA City/State/Zip________________________________________________________

DSA Country____________________________________________________________

DSA Phone Number________________________________________________________________

DSA Email address_________________________________________________________________

DSA Website_______________________________________________________________

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

Special Dietary Needs ______________________________________________________________

Will attend Friday afternoon DSA Network Session. (time to be announced) Yes/No

IMDSA~PO Box 1052~Franklin,TX.~77856~979-828-4177~1-888-MDS-LINK

IMDSA Disclaimer

Registering as an individual indicates that no one is accompanying the applicant at this conference. Including, but not limited to, children, youth, adults, family members, friends and/or co-workers.

A Family registration is considered that one or more family members from applicant's immediate or extended family is attending this conference with the applicant.

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

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.