2019 Board Retreat – Washington, DC

2019 DPC Board Retreat
Washington, DC
December 5 – 8, 2019

Please RSVP no later than Friday, October 25, 2019

We look forward to seeing you!
Please feel free to contact me with any questions at 1 (866) 877 -4242 or rclark@dialysispatients.org.

    I would like a:*
    One King BedOne Queen BedTwo Double BedsHandicap Accessible Room
    Note: DPC will pay for your sleeping room on the nights of December 5 through December 7. If you would like to pay for additional nights on your own, please let us know.

    Do you have any special dietary needs aside from the renal diet?*
    YesNo

    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

    Dialysis

    Will you require dialysis treatment during the retreat?*
    YesNo

    What are your dialysis days?*
    MWFTuThSatOther

    If home hemo, will you be bringing your dialysis equipment with you, or would you rather dialyze in a facility?
    Would like treatment In-CenterI would like to bring my treatment supplies with me

    Emergency Contact Information

    Final Agreement
    I agree to attend the 2019 Board Retreat hosted by Dialysis Patient Citizens December 5-8, 2019. By submitting this form, 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 tremendous time and resources to send 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 Board Retreat. 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.