POSTPONED DUE TO COVID-19

2020 PA Family Day 

Goshen, IN 46528

 

    Please join us by completing the form below and pressing send. (Space is limited.)

    PERSONAL INFORMATION

    NAME (as you would like it listed on name badge)

    Address City

    State Zip Code (required)

    Email Address Phone
    Do you have PA? YesNo

    Event Food will be low protein for PA diet. If you have other food allergies, please specify?

    Are you a presenter, professional or vendor attendee? YesNo

    Is this your first PAF event? YesNo

    INFORMATION OF OTHERS ATTENDING WITH YOU. (For relationship, please type in spouse, child, etc.)

    NAME Relationship

    Age (if child) Does this person have PA? YesNo

    Food Allergies (Please specify)

    NAME Relationship

    Age (if child) Does this person have PA? YesNo

    Food Allergies, please specify

    NAME Relationship

    Age (if child) Does this person have PA? YesNo

    Food Allergies, please specify

    NAME Relationship

    Age (if child) Does this person have PA? YesNo

    Food Allergies, please specify

    NAME Relationship

    Age (if child) Does this person have PA? YesNo

    Food Allergies, please specify

    NAME Relationship

    Age (if child) Does this person have PA? YesNo

    Food Allergies, please specify

    NAME Relationship

    Age (if child) Does this person have PA? YesNo

    Food Allergies, please specify

    NAME Relationship

    Age (if child) Does this person have PA? YesNo

    Food Allergies, please specify

    TOTAL NUMBER ATTENDING LUNCH ON 4/18
    Adults Children (3-12) Children under 3

    PLEASE NOTE ANY OTHER SPECIAL NEEDS:

    I hereby give permission to PAF and CHC to use any photographs taken at the 2020 PA Family Day Conference in which I or members of my family may be a part (for use in, but not limited to, newsletters, websites and reports). YesNo

    In consideration of the acceptance of this registration, I/we the undersigned, assume full responsibility for any injury or accident which may occur while I/we am/are attending the conference events. I/we hereby release and hold harmless the Propionic Acidemia Foundation and Community Health Clinic, its officers, directors, staff, volunteers, members, representatives, agents or assigns associated with this event from any and all personal injury, loss or damages.

    Signature line

    Please prove you are human by selecting the Plane.

    Registration is due by March 15, 2020.