International Myeloma Foundation
Patient & Family Seminar
2009 Registration Form
Please check the city/seminar for which you are registering:
San Francisco, CA
April 17-18 2009
Hotel Niko (415.394.1111)
Dallas, TX
June 26-27 2009
Westin City Center (214.979.9000)
Washington, D.C.
August 7-8 2009
Westin Washington D.C., City Center (202.429.1700)
Minneapolis, MN
August 28-29, 2009
Westin Edina Galleria, (952.567-5000)
Registrant Info:
1)
Patient Spouse Other ________________
First Name
Middle Name
Last Name
Please check one
2)
Patient Spouse Other ________________
First Name
Middle Name
Last Name
Please Check One
3)
Patient Spouse Other ________________
First Name
Middle Name
Last Name
Please check One
4)
Patient Spouse Other ________________
First Name
Middle Name
Last Name
Please Check One
Contact Info: (Please enter contact information for Registrant #1 below)
Address
City
State
Zip
Home Phone
Work Phone
Email
Registration Info:
Package
Package Description
Price per person
Qty
Fee
Total Fee
Friday half-day seminar including Open Forum
with Myeloma Experts; Quality of Life Sessions
A
(1 PM5 PM), welcome cocktail reception &
$60.00 New Lower Price
____ @ $______ $_________
dinner, and
Saturday all-day seminar (8 AM5 PM) with
breakfast & lunch
Saturday all-day seminar, with breakfast &
B
lunch (no Friday seminar or dinner)
$30.00 New Lower Price
____ @ $______ $_________
Name on Badge
City, State
Meal Choice (Package A Only)
1.
Chicken Fish Vegetarian
2.
Chicken Fish Vegetarian
3.
Chicken Fish Vegetarian
4.
Chicken Fish Vegetarian
International Myeloma Foundation
Patient & Family Seminar
2009 Registration Form
Registration Info (continued):
o
Are you a member of a support group? No Yes Which one? ______________________________________________
o
Has the patient been diagnosed for less than one year? No Yes
o
Have you attended an IMF Patient & Family Seminar before? No Yes How Many? ________
o
How did you hear about the seminar?
IMF Mailing Website Myeloma Today/Minute Support Group Friend/Relative Doctor's office
Other ____________________________________________________________________________________
WHAT IS THE #1 THING THAT YOU WANT TO KNOW/LEARN/EXPERIENCE FROM THIS SEMINAR?
Payment Information
I wish to pay by AMEX
DISCOVER
MASTERCARD
VISA
CHECK#
Credit Card Number:
expiration date:
Name as it appears on your credit card:
Deadline for Registrations is the Friday before each seminar
Please make your hotel reservation with the host hotel at least 30 days before the seminar.
Fax or mail this form to:
IMF
12650 Riverside Dr. Ste 206
North Hollywood, CA 91607
Fax: 818-487-7454
01/14/09