2019 Board Retreat – Washington, DC

Name*

Address*

City*

State*
---AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingDistrict of Columbia

Zip*

Phone*

Email*

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

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

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Number*

Emergency Contact Relationship*

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.