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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
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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New Hampshire
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New York
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Ohio
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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)
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If you are encountering any problems filling out the form please call (888)597-7674 for assistance.
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