North Carolina Rare Action Network (NC RAN) Brain Change Workshop Survey

1.First name(Required.)

2.Last name(Required.)

3.Email address(Required.)

4.Phone number(Required.)

5.What town do you live in?(Required.)

6.What state do you live in?(Required.)

8.Please describe any dietary restrictions or allergies you have. If none, please write "N/A"(Required.)

9.Please describe any accommodations you require to participate in this event. If none, please write "N/A".(Required.)

10.Photo Release Form(Required.)

I grant the National Organization for Rare Disorders the right to take photographs of all registered guests in my group in connection with this event. I authorize NORD to copyright, use and publish these photos in print or electronically. I agree that NORD may use such photographs of me with or without my name and for any lawful purposes of publicity, illustration, advertising, social media (Facebook) and web content.

I do not grant the National Organization for Rare Disorders the right to take photographs of all registered guests in my group.