FL COPD Community Workshop Registration 1. COPD Workshop- Ft. Myers, FL November 1st Event InformationLee Memorial Health SystemGulf Coast Medical CenterCommunity Room13861 Doctors WayFt. Myers, FL 33912Free parking on-site Question Title Question Title * 1. Name Name: * Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: * Phone Number: * Question Title * 2. Organization Question Title * 3. I am a Patient Caregiver Respiratory Therapist Nurse Physician Other (please specify) Question Title * 4. I heard about this workshop through COPD Foundation Lee Memorial Hospital Alpha-1 Foundation Florida Society for Respiratory Care Florida Cardiovascular and Pulmonary Rehabilitation Association American Lung Association of Florida Other (please specify) Question Title * 5. Please indicate if you will require back-up oxygen during the workshop or any other accommodations that may be required for you to participate. Question Title * 6. Please indicate if you will require wheelchair assistance during the workshop or any other accommodations that may be required for you to participate. Register