2020 Illinois Advocacy Day Event Registration

Biographical Information

Salutation*
—Please choose an option—Mr.Ms.Mrs.Dr.Rev.

First Name*

Middle Name

Last Name*

Email Address*

Street Address*

City*

State*
—Please choose an option—AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingDistrict of Columbia

Zip Code*

Cell Phone*

Are you willing to have your contact information shared with fellow Patient Ambassadors?*
Yes, you may share my contact information.No, you may not share my contact information.

We encourage Patient Ambassadors to work together. If you are comfortable consenting to sharing your information, we would like to provide your contact information to your fellow Patient Ambassadors in your state or region to help you coordinate. We will not provide any of your information to third parties or anyone outside DPC and the Patient Ambassador program.

Which of the following best describes you?*
—Please choose an option—In-Center HemodialysisHome HemodialysisPeritoneal DialysisFamily MemberTransplant RecipientChronic Kidney Disease (Pre-Dialysis)

Guest Information

Are you bringing a family member/friend/caregiver?*
YesNo

[group guest-name-relationship]
Guest's Name:*

Relationship:*

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Dietary Concerns

Are you vegetarian?*
YesNo

[group guest-vegetarian]
Is your guest vegetarian?*
YesNo
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Are you gluten-free?*
YesNo

[group guest-gluten-free]
Is your guest gluten-free?*
YesNo
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Travel
Where would you like to be picked up?*
—Please choose an option—ChicagoJolietI am taking care of my own transportation to Springfield.

Do you have any needed accessibility accommodations that we should be aware of? If so, describe in the box below:

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Number*

Emergency Contact Relationship*