Title
Please Select
Dr.
Mr.
Mrs.
Ms.
Full Name
*
First Name
Last Name
Affiliation
E-mail
*
example@example.com
Country
*
Province/State
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which Day do you plan to attend?
*
Day 1-August 15th
Day 2-August 16th
Both
Select which applies, are you a:
*
Physician
Individual with Sickle Cell Disease
Nurse
Patient Family Member
Other Allied Health Professional
Researcher
Community Advocate
Industry Partner
Student
Summit Speaker
Sponsor
Other
Do you require CME credits?
*
Yes
No
What is your Specialty?
What is the name of your organization?
Select your ticket and pay
*
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( X )
Patients & Families
$20.00 CAD
$
20.00
CAD
Industry Partner
$100.00 CAD
$
100.00
CAD
Physician
$75.00 CAD
$
75.00
CAD
Nurses and Other Allied Health Professionals
$50.00 CAD
$
50.00
CAD
Researcher
$50.00 CAD
$
50.00
CAD
Student
$20.00 CAD
$
20.00
CAD
Community Advocate
$20.00 CAD
$
20.00
CAD
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
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