2020 Illinois Advocacy Day Event Registration

    Biographical Information


    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?*

    Guest Information

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

    Dietary Concerns

    Are you vegetarian?*

    Is your guest vegetarian?*

    Are you gluten-free?*

    Is your guest gluten-free?*


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

    Emergency Contact Information