The Villages COPD Workshop: What You Need to Know About COPD-Oxygen, Advocacy and Relevant Research

Registration

Please complete the information below to register for the workshop. If you have any questions you can call 1-866-316-COPD (2673) or email Jenny Sculley at jsculley@uic.edu.

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* 1. Name

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* 2. Optional: Organization

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* 3. Optional: Title

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* 4. Address

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

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* 5. Telephone

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* 6. Email Address

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* 7. I am a

Patient

Caregiver

Respiratory Therapist

Nurse

Physician

Other (please specify)

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* 8. I heard about this workshop through

COPD Foundation

Villages Airheads

Florida Society for Respiratory Care

Alpha-1 Foundation

American Lung Association of Florida

Villages Regional Hospital

Villages Health

Other (please specify)

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* 9. Do you use oxygen

Yes-24 hours a day

Yes-only with sleep and/or exercise

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* 10. Please select any accommodations that you will require while attending the workshop.

Wheelchair assistance from the parking lot

Electrical outlet for plugging in an oxygen concentrator

Dietary restrictions (please enter in the other field below)

Other (please specify)

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* 11. All participants are encouraged to bring adequate oxygen supplies for the duration of the workshop. If oxygen is a barrier for you to attend please indicate so and a staff member will follow up to determine how we can assist.

I require backup supplemental oxygen in order to attend