LGMD Patient Day Registration
Submit
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Dietary Restrictions
Gluten Free
Dairy Free
Vegetarian
Vegan
Other
If Other, Please Describe:
How many guests will be coming with you?
If so, please list their names:
Do you consent for University of Kansas Medical Center (KUMC) to use or disclose photographs or other identifying images of you (or your child)?
Yes
No
Should be Empty: