VWD Connect Foundation 2024 Provider Education Workshop on Severe VWD
Attendee Registration Form
Personal Information
First Name
*
Last Name
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Name as you'd like it to appear on your badge (please indicate Dr., M.D., etc):
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Institution as you'd like it to appear on badge:
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City & State for badge
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Home Address
*
Street Address
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City
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Email
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example@example.com
Cell Phone Number (so we can reach you on-site)
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Date of Birth
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Gender
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Prefer not to say
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Discipline/Specialty
*
Adult Hematology
Pediatric Hematology
Hematology/Infusion Nursing
Orthopedics
Physical Therapy
OB/Gyn
Gastrointestinal
Family/Maternal Medicine
Genetic Counsellors
Hematology Social Workers
Other
Do you work with severe Von Willebrand Disease patients?
*
Yes
No
Expect to in the future
Do you work at an Hemophilia Treatment Center (HTC)?
*
Yes
No
Expect to in the future
Why do you want to attend the Workshop?
*
How did you hear about the Workshop?
*
Colleague recommended
Patient recommended
Other organization communication
VWD Connect website/email
Other
Please enter the name of the referring person/organization if applicable
Do you have a case you would like to present for discussion at the Workshop?
*
Yes
No
Not sure
What is a medical topic or question on Severe VWD you hope will be addressed at the Workshop?
*
Do you have an interest in joining the Faculty for the VWD Connect Patient Conference being held July 18-21, 2025?
*
Yes
No
Unsure
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Hotel Booking and Accomodations
The Workshop begins at 5:00 PM on Friday, November 8th and ends Sunday, November 10th at 3:00 PM. The Foundation will provide a hotel room for each attendee on Friday and Saturday night. If your travel arrangements require you to stay Sunday night to be able to complete the Workshop program at 3:00 PM, we will also provide a hotel room Sunday night. If you wish to reserve additional nights at the hotel utilizing our block rate of $190/night, please use the link that will be provided in the confirmation email you will receive once you submit this registration.
Please indicate below what nights you will need a hotel room
Friday, November 8th - 1st Workshop Night
Nov 8
*
Yes
No
Saturday, Nov 9th - 2nd Workshop Night
Nov 9
*
Yes
No
Sunday, Nov 10th (Only if necessary to accommodate travel)
Nov 10
*
Yes
No
What room type would you prefer?
*
Two double beds
One king bed
No preference
Do you require any special room accommodations?
Do you have any dietary restrictions/needs?
IMPORTANT TRAVEL INFORMATION
The West Palm Beach Marriott is approximately 3 miles from the Palm Beach International Airport (PBI). The hotel provides complimentary shuttle service. If flying, once you book your flights please email your itinerary to: JCesta@VWDConnect.org so we may plan arrival and departure staffing.
How will you be travelling to the Conference?
*
Flying
Driving
Other
Please complete your estimated arrival and departure dates and times below.
Arrival date?
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-
Day
Year
Date
Estimated arrival time?
*
Hour Minutes
AM
PM
AM/PM Option
Departure date?
*
-
Month
-
Day
Year
Date
Estimated departure time?
*
Hour Minutes
AM
PM
AM/PM Option
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Emergency Contact Information
Emergency Contact
*
First Name
Last Name
Relationship to Attendee
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
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Consents
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