Experts in Arthritis Registration Form - New Orleans, LA

1. Experts in Arthritis Seminar

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Please join us for an afternoon with world-class experts in arthritis care who will inform you about current scientific evidence and management strategies in the treatment and care of osteoarthritis, rheumatoid arthritis, and juvenile arthritis.

Date:______May 22, 2012_____

Time:________2:00 to 5:00 PM__

Location:__Tulan Medical Center,New Orleans, LA

1. Please Register Below:

Please Register Below: Name:
Company/Organization (if applicable):
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Email Address:
Phone Number:

2. What is your relationship to the disease?

What is your relationship to the disease? Person with Arthritis

Caregiver

Family Member

Professional

3. What is your area of interest?

What is your area of interest? Osteoarthritis

Rheumatoid Arthritis

Juvenile Arthritis

Other (please specify)

4. Please list a question(s) you would like the experts to answer.

Please list a question(s) you would like the experts to answer.

5. How did you hear about the seminar?

How did you hear about the seminar? American College of Rheumatology (ACR)

Arthritis Foundation

Centers for Disease Control and Prevention (CDC)

Friend/Colleague

Occupational Therapist

Physical Therapist

Public Library

Radio

Registered Day of Event

Rheumatologist

Senior Center

U.S. Bone and Joint Initiative Website

Other (please specify)

PHOTO RELEASE
I hereby grant the U.S. Bone and Joint Decade/Initiative and its affiliates specific permission to reproduce, publish, circulate copyright or otherwise use any and all photographs and/or electronic reproductions (slides, video) of myself taken at the Experts in Arthritis Seminar.

Signature:______________________________________________

Print Name:_____________________________________________

Date:__________________________________________________

6. Would you be interested in obtaining updated information regarding arthritis and related diseases?

Would you be interested in obtaining updated information regarding arthritis and related diseases? Yes

7. For Office Use Only: Attended Session

	Yes	No
Attended	*For Office Use Only: Attended Session Attended Yes	Attended No

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