Vitiligo Support International - Vitiligo Support Conference Registration

VITILIGO SUPPORT
2008 NATIONAL CONFERENCE
Friday to Sunday, July 11-13, 2008

Registration

SECURE ONLINE REGISTRATION

This registration page is secure and all information sent is encrypted. Should you have a problem, please use our Contact Us page.

Once you complete the form, click the submit button at the bottom of the page and you will be taken to the payment options page. Mastercard, Visa, Discover and American Express are accepted securely online. Registration for adults is $145.00 per person which includes Friday afternoon program and welcome reception, Saturday: breakfast, presentations, exhibits, lunch,and Saturday evening dinner and entertainment. Children 5 to 12 are $85.00 each, which includes participation in our children's program.

(* = required field)

Section 1 - Registrant Name

* Prefix:

* First Name:

Middle Initial:

* Last Name:

Suffix (Jr., Sr. etc.):

Section 2 - Your Name Badge

* First Name (preferred):

* Last Name:

Your VitiligoSupport User ID
(optional but encouraged so other website members may know who you are!)

* City:

* U.S. State (or country if outside U.S.):

Section 3 - Mailing Address & Contact Information

* Street Address:

Street Address 2:

Apt/Unit/Suite #:

* City/Town:

* State, Province or County:

* Zip or Postal Code:

* Country:

* Phone (please include area code/country code if applicable):

Cellphone: (optional)

* Email Address:

* For confirmation, please retype your Email Address:

* Person to notify in case of emergency during the conference:

* Name:

* Phone Number:

Section 4 - Others in your Group

Person 2 Name: Age (if Child):

Person 3 Name: Age (if Child):

Person 4 Name: Age (if Child):

Person 5 Name: Age (if Child):

Unfortunately we are unable to accomodate children under the age of 5.

Section 5 - Evening Event Attendance

Friday and Saturday evening events are covered by our event sponsors and are included at no additional charge for all paid attendees. However, we are charged by the head and are required to provide an accurate head count to the hotel.

Will you attend Friday afternoon educational session?:

Will you attend the Friday evening Welcome reception?:

Will you attend Saturday evening's dinner and social event?:

Section 6 - Sunday Brunch

Would you like to purchase a voucher for the hotel's Sunday brunch? (Discounted price of $15.00 per person):

Section 7 - Comments

Comments(optional):

Section 8 - Release/Waiver

Liability Waiver *: The planners and sponsors of the 2008 Vitiligo Support National Conference claim no liability for the safety of any attendee during this event or while in transit to or from this event. The planners and sponsors of this function shall not be liable for any delays or failure in performance or interruption of services resulting directly or indirectly from any cause or circumstance beyond the reasonable control of the organization including but not limited to, acts of God, acts of public enemy, war, accidents, fires, electrical failures, strikes, labor disputes, postal delays, governmental order or regulations.

The total amount of any liability of the planners and sponsors of the 2008 Vitiligo Support Conference will be limited to a refund of the registration fee. Conference participants are responsible for their own well being, and that of their children, and neither Vitiligo Support International, Inc., nor the planners, sponsors and presenters will be held liable for any injury or death to any participant during the conference.

I understand that at this event or related activities, I may be photographed. I agree to allow my photo, video or film likeness to be used for any legitimate purpose by Vitiligo Support International. Should I not wish my likeness to be used by Vitiligo Support International, I will have the option at the conference to refuse the use of my likeness.

Organizers of this function and Attendees of this function, under the terms of registration, agree to indemnify and hold harmless each other from and against all claims, actions or causes of action, and/or liabilities arising out of or resulting from any act taken or committed by the attendees, organizers, sponsors or presenters of the conference, except for the willful misconduct or gross negligence of the other party.

Information learned and obtained at the 2008 Vitiligo Support National Conference is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding vitiligo or any other medical condition.

Vitiligo Support International does not recommend or endorse any specific treatments, tests, studies, products, procedures, opinions, or other information that may be learned about, demonstrated, covered or mentioned during the conference. Reliance on any information obtained or learned at the conference is solely at your own risk. Always consult your physician before undergoing or using any treatment, procedure or product.

* I AGREE