Register for SJIA Family Conf (Virtual Edition)

Register for SJIA Family Conf (Virtual Edition)

Dec 2nd - Dec 4th, 2020. Daily 8am - 12pm EST.
- The conference will be conducted via Zoom.
  
  Zoom link for all days: https://us02web.zoom.us/j/86594884834
  
  All times below in Eastern Standard Time (EST)
  Wed, Dec. 2, 8:00am - 12:00pm
  Thurs, Dec. 3, 8:00am - 12:00pm
  Fri, Dec. 4, 8:30am - 12:00pm
  
  The final schedule can be found here.
  
  You will be able to use the chat feature to make comments or ask questions. When you log in, please use your full name.
  
  Need Help
  If you need assistance while you are in the Zoom Conference, please Private Chat with “Helpdesk” to troubleshoot any issues.
  
  If you have issues logging into the Zoom Conference, please email av@evolutioneventsolutions.com for assistance.
  
  We’re looking forward to connecting with you virtually!
- After registering, you will receive registration confirmation.
- Note for patients: This conference brings together top scientific experts from across the world. The sessions on the first day are scientific in nature but geared towards patient education. Previous patient attendees feel that they understand disease and treatments better by attending the conference.
Attendee Category *
Prefix
Gender *
First Name *
Last Name *
E-mail *
Phone number *
Give number easiest to reach you at in case of any technical issues during conference
Company / Affiliation
Give name of your hospital/clinic/company
Position
You job title at organization listed above
Location *
City / Country you live in
Will this be your first time at SJIA Family Conference?

Yes, this will be first time No, I have attended previously
SJIA / Still's Patient Information

(Understanding who is attending helps us keep program relevant)
Are you a patient / caregiver / other family member of the patient? *

I am the Patient I am the Parent / Primary Caregiver I am Family / Friend of the Patient
Which category best fits the SJIA / Still's patient? *

Is a child (below 18) Is an adult now, but diagnosed as a child Is an adult diagnosed as an adult
Age of Patient *
Give age in years
Which of these complications has patient had? (only check if it has been a persistent issue) *

Recurrent MAS (Macrophage Activation Syndrome) Persistent Arthritis Lung Complications Liver / Kidney Complications CNS / Brain complications Persistent Gastro-intestinal issues (suspected or confirmed IBD / Crohns etc)
Has patient been diagnosed with (or suspected of) INTERSTITIAL LUNG DISEASE. If so, describe diagnosis & symptoms.
describe lung complications above
How would you describe patient's current status with SJIA / Still's?

Under control WITH medications Under control WITHOUT medications NOT under control (has active disease / complications)
Would you like to learn about research studies for SJIA / Still's that you can participate in (some are online)?

Yes! No
Audio & Visual Release: By completing this registration form, you give the Systemic JIA Foundation permission to take and use your picture and/or videotape you, and to use your image for any purpose related to this conference / marketing the foundation.

Questions / Suggestions?
Please email events@systemicjia.org with any questions.
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Register for SJIA Family Conf (Virtual Edition)

SJIA / Still's Patient Information