2019 DPC Board Retreat
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 firstname.lastname@example.org.
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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?*
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
Will you require dialysis treatment during the retreat?*
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
Home dialysis center name:*
Home dialysis center phone number:*
Home dialysis center fax number:
Home dialysis center travel coordinator or social worker:*
Emergency Contact Information
Emergency Contact Name*
Emergency Contact Number*
Emergency Contact Relationship*
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.
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.