Please
Print and Return this form with Registration Fee as soon as
possible, but no later than June 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 Street
Oakland, CA
94610 USA
For Further Information: Phone: 800-392-8458 Fax: 559-222-7997 Email: Email@cystinosis.com
Name:
__________________________________________________________________________
Mailing
Address:
_________________________________________________________________
Phone:
__________________ Fax: ___________________
Email:__________________________
Please circle:
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: ____________ Shirt
Size:_________ Cystinosis: Yes
No
Name: __________________________
Gender: ____________ Shirt Size:_________ Cystinosis: Yes
No
Name: __________________________
Gender: ____________ Shirt Size:_________ Cystinosis: Yes
No
Children Attendee's:
Name:
__________________________ Gender: ____________ Shirt Size:_________
Cystinosis: Yes No
Name:
__________________________ Gender: ____________ Shirt Size:_________
Cystinosis: Yes No
Name:
__________________________ Gender: ____________ Shirt Size:_________
Cystinosis: Yes No
Name:
__________________________ Gender: ____________ Shirt Size:_________
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:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________