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Mail to: BMT Infonet c/o CONDOR Registration Services P.O.Box 3348 Huntsville, AL 35810 Fax to: (256)852-6838

ATTENDEE INFORMATION (enter only one name per blank)

First Name:   Last Name:   Age:   Title:   Mailing Address:   City:   State or Province: -----UNITED STATES----- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -----CANADA----- Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan -----OTHER COUNTRY----- Other (please specify)     ZIP/Postal Code:   Country:   Home Phone:   Work or Cell Phone:   Email:   Relationship to the Survivor: This Attendee is a survivor Parent of transplant survivor Spouse/Partner of transplant survivor Sibling of transplant survivor Child of transplant survivor Grandparent of transplant survivor Friend of transplant survivor Health Care Professional not related to a survivor Other   Please Specify Relationship:

NOTES: Young Adult Session (suggested for survivors ages 18-30) Pediatric Session

Saturday, March 20:       Track Selection I will attend the sessions about pediatric survivors I will attend the sessions for young adult survivors (suggested for ages 18-30) I will attend the sessions for adult survivors I will not be attending the sessions

Sunday, March 21 Workshop Selection:       8:00 am - 9:00 am Coping with Chemobrain - also at 10:30 Learning & Memory Challenges in Children (pediatric) Complimentary Medicine - also at 10:30 Employment Rights & Disability Insurance Options Female Sexuality After Transplant Managing Finances after Transplant I will not be attending this workshop 9:15 am - 10:15 am Chronic Graft-versus-Host Disease - also at 11:45 Caregiver Challenges (pediatric) Caregiver Challenges (adults) - also at 11:45 Spirituality: Coping with Changes from Transplant Male Sexuality After Transplant Family Planning After Transplant (suggested for ages 18-30) I will not be attending this workshop 10:30 am - 11:30 am Coping with Chemobrain - also at 8:00 Ask the Experts (pediatric) - also at 11:45 Complimentary Medicine - also at 8:00 Navigating the Insurance Maze - also at 11:45 Ask the Experts (adults) - also at 11:45 Financial Management for Young Adults (suggested for ages 18-30) I will not be attending this workshop 11:45 am - 12:45 am Chronic Graft-versus-Host-disease - also at 9:15 Ask The Experts (pediatric) - also at 10:30 Caregiver Challenges (adults) - also at 9:15 Navigating the Insurance Maze - also at 10:30 Ask the Experts (adults) - also at 10:30 Relationships & Intimacy for Young Adults (suggested for ages 18-30) I will not be attending this workshop

Dietary Restrictions:

Do you have any other special needs (such as help with walking)?

SURVIVOR INFORMATION

First Name:   Last Name:   Age:

What year was your most recent transplant?   Age at Time of Transplant?   What is the name of the hospital where the transplant was performed?   What was the Diagnosis? Acute Myelogenous Leukemia (AML) Acute Lymphoblastic Leukemia (ALL) Chronic Myelogenous Leukemia (CML) Chronic Lymphocytic Leukemia (CLL) Hodgkin's Disease Non-Hodgkin's Lymphoma Mantle Cell Lymphoma Burkitt Lymphoma Myelodysplasia Myeloproliferative Disorder Severe Aplastic Anemia Sickle Cell Disease Breast Cancer Waldenstrom's Macroglobulinemia Amyloidosis Multiple Myeloma Brain Tumor Ewing's Sarcoma Fanconi Anemia Immunodeficiency Krabbe Disease Mylofibrosis Neuroblastoma SCIDS Thalassemia Wiskott-Aldrich Disease Other(please specify)     What type of transplant was performed? Autologous (used your own marrow or stem cells) Related Donor Transplant Unrelated Donor Transplant

AMERICANS WITH DISABILITIES ACT

Please let us know by February 15, 2010 if you have special needs for which we must make accommodations such as wheel chair accessibility, assistance for the blind or hearing impaired, etc. Phone (888)597-7674.

COMMENTS or SUGGESTIONS

Let us know if there is anything else we can do to be of assistance, or if you have any suggestions regarding the event.

REGISTRATION FEES

Attendee Information Cost     Attendee #1: Up to two scholarships are available for survivors and their family members who are unable to afford the registration fee. Scholarships are not available for health care providers not related to a survivor. Scholarships Needed: 0 1 >2     Donation: $ If you would like to make an additional donation to help pay for the symposium, please enter it here. Total:

PAYMENT

Check/Money Order      (made payable to BMT Infonet) VISA MasterCard American Express Discover Card Number:   Cardholder's Name:   Expiration Date: 01 02 03 04 05 06 07 08 09 10 11 12 / 2010 2011 2012 2013 2014 2015   Verification Code:   Billing ZIP:

If you are encountering any problems filling out the form please call (888)597-7674 for assistance.