2014 ARVD/C Seminar Registration

1. Default Section

 
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Please complete one registration form for each person attending. You will be redirected to the beginning of the registration form at the end of the survey. Please include a valid email address as that is how you will receive confirmation materials relating to this event. If you have any questions regarding the seminar, please contact Crystal Tichnell, MGC at ctichnell@jhmi.edu or 410-502-7161.
1. Contact Information
2. Would you like to be included on our mailing list?
3. What is your year of birth?
4. Have you been diagnosed with ARVD/C?
5. Do you have a family member that has been diagnosed with ARVD/C?
6. Have you attended one of our ARVD/C seminars in the past?
7. If you have not already done so, are you interested in participating in genetic RESEARCH by donating a blood sample during the seminar? (This is not for clinical genetic testing.)
8. Are you interested in participating in other available research opportunities? (specific opportunities to be announced, but may include Holter monitoring hookup, ICD interrogation, etc)
9. Do you have an ICD?
10. If YES, what type of device do you have?
11. Are you staying at the Hilton Garden Inn - Inner Harbor?
12. A bus will be available to transport you from the Hilton Garden Inn-Inner Harbor to the seminar location Saturday morning, as well as back to the hotel in the afternoon. Do you need to reserve a seat on the bus FROM THE HOTEL traveling TO THE SEMINAR Saturday morning?
13. Do you need to reserve a seat on the bus FROM THE SEMINAR back TO THE HOTEL Saturday afternoon? (Cabs are available at your own expense)
14. There will be Meet 'n Greet Reception with heavy hors d'oeuvres served on Friday evening from 7:00pm-9:00pm at the Hilton Garden Inn-Inner Harbor for individuals and family members affected by ARVD/C to socialize. Do you plan to attend?
15. Are you interested in sharing your story with others? (presentation at the ARVD/C seminar or on our website, www.arvd.com)
16. Do you need any special accommodations (ie. wheelchair)?
17. Additional comments: