Annual Advocacy Day RSVP

    Are you a Patient Ambassador or Board Member?*
    Patient AmbassadorBoard Member

    What is your date of birth?*

    Hotel Accommodations

    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

    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:

    Final Agreement
    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.