Cystinosis Foundation International Conference 2004
On-Line Registration Form

Please Fill in Boxes and Click Submit this form will be sent to the Cystinosis Foundation via Email.
The Registration Fee should be mailed as soon as possible, but no later than July 1, 2004 to:
(Registration Fee is: $10 per Individual, or no more than $25 per family)

Cystinosis Foundation
Cystinosis International Conference 2004 Registration
604 Vernon Steet
Oakland, CA 94610 USA

For Further Information:           Phone: 800-392-8458           Fax: 559-222-7997           Email: Email@cystinosis.com


** Please DO NOT use the ENTER key, use the TAB key or your MOUSE to move between textboxes **
Once you click SEND, you will come back to this form, click the BACK button to continue.

Name:

Street Address:

City, State, & Zip:

Phone:   Fax: Email:

Please Check One:    Parent          Adult with Cystinosis       Medical Professional          Relative          Other

How many in your party? Arrival date: Departure date:

Will you be staying at the Hotel Ciutat De Tarragona?       Yes       No

Adult Attendee's (Please include all adults attending):
Name: Gender: Cystinosis:   Yes       No
Name: Gender: Cystinosis:   Yes       No
Name: Gender: Cystinosis:   Yes       No

Children Attendee's:
Name: Age: Gender: Cystinosis:   Yes       No
Name: Age: Gender: Cystinosis:   Yes       No
Name: Age: Gender: Cystinosis:   Yes       No
Name: Age: Gender: Cystinosis:   Yes       No

Please specify any Cystinotic food preferences of the child:

Please specify any Special Accommodations for any persons in your party: (handicap room, sign interpreter, microwave)

Please list questions that you would like answered at the Conference:
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5.

If you have questions regarding this Registration or the Online Form. Please fill in the box below.