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2017 NBIA Disorders Association Family Conference Registration
  1. Please list the first and last name of everyone attending the conference. This registration is for all persons in one household with the same address. If a separate household, with different address, please register separately.

  2. Name(s) of Attendees:
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  3. Address
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  4. Address 2
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  5. City
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  6. State
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  7. Zip Code / Country Code
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  8. Country
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  9. Phone Number
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  10. Email Address
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  12. Are you willing to have your contact information included on a list of participants?
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  14. Please indicate all of the events that you will be attending:
  15. Registration: Thursday 4:00 – 7:00 pm
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  16. Happy Hour/Getting to Know You Session: Thursday 6:00 – 9:00 pm
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  17. Lunch: Friday
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  18. Picnic: Saturday
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  19. Dessert Social: Saturday Night
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  20. Adult NBIA Individual Only: Session with counselor Sunday morning
    (over 18, capable of attending session alone)
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  21. Sessions and Closing Ceremony: Sunday morning
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  23. Do you require vegetarian meals?
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  24. Do you require gluten-free meals?
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  25. Any food allergies or other dietary restrictions?
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  27. How are you traveling?
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  28. If not driving, do you require a handicap accessible vehicle for transportation while at conference?
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  29. If not driving, do you require transportation to our picnic on Saturday?
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       (It is 6.7 miles from hotel-approximately 12 minute drive)
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  31. Is this your first time attending the conference?
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  32. Are you a first time attendee requesting an appointment with our NBIA Physician Experts on Tuesday, Wednesday or Thursday?
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  33. Are you interested in participating in our Mentor Program matching returning families with first-time attendees?
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  35. How recent is the NBIA diagnosis for your family?





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  36. Please list specific disorder:
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  37.  

  38. Photo/Video Release

    Please read carefully our photo/video release form and accept or decline. If declining, your family will be unable to participate in any group or individual photos/videos taken at conference.


    I hereby give permission to NBIA Disorders Association to use and distribute (not limited to use in newsletters, guides, brochures, videos, appeals, Web site and reports) at their discretion, any photographs or videos taken at the Ninth International NBIA Disorders Association Family Conference, of which I, my friends, or a member of my family may be a part. This release includes all individuals under this family registration.
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  40. Are you interested in receiving a RARE Bear at the family conference for NBIA individual(s) in your family?
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  42. Will any family members be using the Care Room?
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       If yes, must agree to waiver for care room participants below as either the parent(s)/legal guardian(s) of minor child or legal guardian(s) of adult. Please read information for care room details before signing appropriate waiver. You will also be required to send in the Care Room Information Form before registration of those using the care room is complete.
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  44. WAIVER AND ASSUMPTION OF RISK (CHILD)
    I/We are the parent(s) or legal guardian(s) of named individuals, a minor (hereinafter “Child”). Parent voluntarily makes and grants this Waiver and Assumption of Risk in favor of NBIA Disorders Association. including but not limited to employees, contractors, volunteers, agents and all others engaged in efforts on behalf of or at the direction of the aforementioned entity as consideration for Child’s opportunity to use the facilities, equipment, materials and participate in the activities, events, festivities and/or gatherings sponsored by and part of the NBIA Disorders Association family conference; Parent hereby waives and releases any and all claims whether in contract or of personal injury, bodily injury, property damage, damages, losses and/or death that may arise from Child’s aforementioned use or participation, as I understand and recognize that there are certain risks, dangers and perils connected with such use and/or participation, which I hereby acknowledge have been fully explained to me and which I fully understand, and which I accept, assume and undertake after inquiry and investigation of extent, duration, and completeness wholly satisfactory and acceptable to me. I further agree to use my best judgment in permitting Child to engage in these activities, and to fully explain to Child and require compliance with all safety instructions and recommendations, whether oral or written. I hereby certify that I am a competent adult, executing this Waiver of my own free will, being under no compulsion or duress. This Waiver and Assumption of Risk is effective from June 1, 2017 to June 4, 2017, inclusive, and may not be revoked, altered, amended, rescinded or voided without the express prior written consent of NBIA Disorders Association.
  45. Name of child/children in care room
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  46. Name of parent(s) or legal representative(s)
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  47. I/We agree as their parent(s) or legal representative(s) to this waiver of assumption of risk for named child/children
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  49. WAIVER AND ASSUMPTION OF RISK (ADULT)
    I/We voluntarily make and grant this Waiver and Assumption of Risk in favor of NBIA Disorders Association, including but not limited to employees, contractors, volunteers, agents and all others engaged in efforts on behalf of or at the direction of the aforementioned entity as consideration for the opportunity to use the facilities, equipment, materials and participate in the activities, events, festivities and/or gatherings sponsored by and part of the NBIA Disorders Association Family Conference; I/We hereby waive and release any and all claims whether in contract or of personal injury, bodily injury, property damage, damages, losses and/or death that may arise from my aforementioned use or participation, as I/We understand and recognize that there are certain risks, dangers and perils connected with such use and/or participation, which I hereby acknowledge have been fully explained to me and which I fully understand, and which I accept, assume and undertake after inquiry and investigation of extent, duration, and completeness wholly satisfactory and acceptable to me. I/We further agree to use my best judgment in undertaking in these activities, and will faithfully adhere to all safety instructions and recommendations, whether oral or written. I hereby certify that I am a competent adult, executing this Waiver of my own free will, being under no compulsion or duress. This Waiver and Assumption of Risk is effective from June 1, 2017 to June 4, 2017, inclusive, and may not be revoked, altered, amended, rescinded or voided without the express prior written consent of NBIA Disorders Association.
  50. Name of adult in care room
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  51. I/We agree as their legal representative(s) to this waiver of assumption of risk for named adult
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  52.  

  53. Registration Fees:









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  54. Total:
    0.00 USD
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  56. More Information about Attendees (if applicable):
  57. 1st NBIA Individual's Name
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  58. Do they have a g-tube for feeding?
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  59. 2nd NBIA Individual's Name
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  60. Do they have a g-tube for feeding?
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  61. Name & Age of 1st Child under 7
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  62. Name & Age of 2nd Child under 7
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  64. Additional Comments:
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  66. When you click the button below you will be taken to the secure payment page. You can choose a way to pay. You may Pay with a Debit or Credit Card or Pay with your PayPal Account. You do not need to have a PayPal account or create a PayPal account in order to pay securely online.
  67. Security Code
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