Are you a Patient Ambassador or Board Member?*
Patient AmbassadorBoard Member
What is your date of birth?*
DPC staff will do their best to accommodate your needs. We will guarantee coverage for May 31 through June 1. (Check out is on June 2).
DPC staff will do their best to accommodate your needs. Board members will need to arrive a little earlier than the rest of the attendees. There will be a full-day board meeting on Sunday, May 31. All board members should plan on arriving Saturday, May 30.
I would like a:*
One King BedOne Queen BedTwo Double BedsHandicap Accessible RoomOther
Are there any additional accommodations required?*
Please describe the additional accommodations that are required:*
Do you have any special dietary needs aside from the renal diet?
Please describe dietary needs aside from the renal diet:*
Will you require a wheelchair at any time?*
Yes, all of the timeYes, but only for long distancesYes, but I will be bringing my own wheelchairNo
Emergency Contact Information
Emergency Contact Name*
Emergency Contact Number*
Emergency Contact Relationship*
Which of the following best describes you?*
In-Center HemodialysisHome HemodialysisPeritoneal DialysisTransplant RecipientFamily MemberPartner in Care
What are your dialysis days?*
Will you be bringing your dialysis equipment with you, or would you rather dialyze in a facility?*
I will send my machine and materials ahead of time and dialyze in the hotel.I will dialyze in-center.
Do you have any special dialysis needs? If so, describe in the box below:
Home dialysis center name:*
Home dialysis center phone number:*
Home dialysis center travel coordinator:
I agree to attend the 2020 Advocacy Day hosted by Dialysis Patient Citizens May 31 to June 2. I agree to take responsibility for my care and will let DPC staff know how they may help, if there are any changes in my condition, as well as if I need any additional accommodations. I understand that DPC is investing time and resources to bring me to Washington, DC, and I agree to do my best to uphold my commitment to attend all of the meetings and activities during the Fly-In. If health reasons prohibit me from attending, I will contact DPC as soon as possible to let them know.
Do you agree to these terms? *
Yes, I agree to these terms.
1012 14th St NW, Suite 1475 Washington DC, 20005
Dialysis Patient Citizens
Dialysis Patient Citizens (DPC) is the nation’s largest patient-led organization working to improve the quality of life for dialysis patients. Join us in making a difference for those with kidney disease by enrolling as a DPC member today. (Membership is free.)
We need your help to remind policy makers that we are real people and not just a line-item in their budget. You can make a huge impact by calling, emailing, or writing to share your story with your elected officials.
Act now to ensure your voice is heard, and to sign-up so that we keep you up-to-date on the issues that impact you and your family.