First International Meeting - Together for Dias-Logan Syndrome (BCL11-A)

First International Meeting - Together for Dias-Logan Syndrome (BCL11-A)

Registration Request Form
📅 June 3, 4 and 5, 2027

📍 Azureva Centre – Ronce-les-Bains, Charente-Maritime (France)

This event will bring together families, researchers and clinicians from around the world for the first time.

Accommodation and meals fully provided (2 nights / 3 days)

Places are limited. This form constitutes a registration request. Confirmation will be sent to you after validation.
General Information
Name of person completing form

First NameLast Name
E-mail
example@example.com
Telephone Number with Country Code
City
Country
Main language
Other languages spoken
I am a:

Other
If other, please specify
Profile of Person(s) Diagnosed with Dias-Logan Syndrome
First name(s)
Please list all family members diagnosed with Dias-Logan Syndrome
Age(s) at time of conference (June 2027)
Please indicate age of each family member diagnosed with Dias-Logan Syndrome
Confirmed diagnosis?
Special needs

Other
Special needs details
Participants
How many people will attend?
Number of adults
Number of children
Children's ages
How many night(s) will you require accommodations?
Please note, the association will cover a two-night stay for June 3 and 4. Additional nights will be at participant's own expense.
Do you require a room for a person with reduced mobility?
Do any members of your party have dietary restrictions?
Please describe dietary allergies or other dietary needs
Do you require any other special accommodations due to medical needs?
Transportation
Planned mode of transportation
Will you need help organizing arrival?
Arrival assistance details
Scientific Conference Day (Friday, June 4)

Language translation will be available via mobile app + headset
Will you attend the Scientific Conference Day on Friday, June 4?
What topics are you interested in during the Scientific Conference Day?

Other
Other topic(s) or comments
Activities & Program
You are attending mainly to:

Other
If other, please specify
Why do you want to participate in this event?
What are you expecting from this event?
Consent
I understand that places are limited. I understand that this form constitutes a registration request. I will be notified via the email provided once registration is confirmed. I agree to notify the association as soon as possible if I need to cancel my request.
May the association to contact you in the future regarding other events and news?
Preferred method of contact
Thank you for registering, we will be in contact soon.
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First International Meeting - Together for Dias-Logan Syndrome (BCL11-A)

General Information

Profile of Person(s) Diagnosed with Dias-Logan Syndrome

Participants

Transportation

Scientific Conference Day (Friday, June 4)

Activities & Program

Consent

Thank you for registering, we will be in contact soon.