Individual and Family Registration Form
Immune Deficiency Foundation - 2015 National Conference: June 25-27, 2015
Hyatt Regency • New Orleans, Louisiana
Full payment is due at time of registration.
STEP I – General Meeting Registration
IDF-1114-270
Circle One:
Mr. / Ms. / Mrs. / Dr. First Name*:
Last Name*:
Address*:
City*:
State*:
Primary Phone*:
Postal Code*:
Primary Email*:
Are you affected by a PIDD?
YES
NO If “yes”, please indicate diagnosis below:
Alpha One Antitrypsin Deficiency
Hyper IgM
Alpha One Genetic Empaxsoma
Hyper IgM Syndrome
Ataxia Telangiectasia
Hypoaglobulemia/Aspergillosis
Chronic Granulomatous Disease
Hypogammaglobulinemia
Chronic Lymphatic Leukemia
IgG Subclass Deficiency
Chronic Mucocutaeous Candidiasis
IgM Deficiency
Common Variable Immunodeficiency Disease
In-process of being diagnosed
Complement Deficiency
JOBS
DiGeorge Syndrome Anomoly
Leukocyte Adhesion Defect
Discoid Lupus
Lupus
Good Syndrome
Mannose Binding Lectin Deficiency
Hereditary Angiodema
Nemo
Hyper IgE
Neutropenia
I have special needs (ADA requirements, food allergy, etc). Please explain:
*Required Field
PNP Enzyme Deficiency
Selective IgA Deficiency
Severe Combined Immunodeficiency Disease
Specific Antibody Deficiency
Thrombocytopenia
Transient Hypogammaglobulinemia of Infancy
Unspecified Immune Deficiency
Wegener’s
Wiskott-Aldrich Syndrome
X-Linked Agammaglobulinemia
Y-Linked Disorder
Additional Guests or Family Members Attending:
Mr. / Ms. / Mrs. / Dr. First Name*:
Last Name*:
Address*:
Date of Birth (youth only):
City*:
State*:
Primary Phone*:
Postal Code*:
Primary Email*:
*Required Field
Relationship to Primary Registrant:
Spouse/Partner
Child
Parent/Caregiver
Sibling
Friend
Patient
Other Relative
Affected by a PIDD?
YES
NO If “yes”, please indicate diagnosis below:
Alpha One Antitrypsin Deficiency
Hyper IgM
Alpha One Genetic Empaxsoma
Hyper IgM Syndrome
Ataxia Telangiectasia
Hypoaglobulemia/Aspergillosis
Chronic Granulomatous Disease
Hypogammaglobulinemia
Chronic Lymphatic Leukemia
IgG Subclass Deficiency
Chronic Mucocutaeous Candidiasis
IgM Deficiency
Common Variable Immunodeficiency Disease
In-process of being diagnosed
Complement Deficiency
JOBS
DiGeorge Syndrome Anomoly
Leukocyte Adhesion Defect
Discoid Lupus
Lupus
Good Syndrome
Mannose Binding Lectin Deficiency
Hereditary Angiodema
Nemo
Hyper IgE
Neutropenia
This guest has special needs (ADA requirements, food allergy, etc). Please explain:
This guest will be participating in the following Youth Program on Friday & Saturday.
Childcare (Ages 6 months – 5 years)
Tween Scene (Ages 10 – 12)
Kids Club (Ages 6 – 9)
Other:
PNP Enzyme Deficiency
Selective IgA Deficiency
Severe Combined Immunodeficiency Disease
Specific Antibody Deficiency
Thrombocytopenia
Transient Hypogammaglobulinemia of Infancy
Unspecified Immune Deficiency
Wegener’s
Wiskott-Aldrich Syndrome
X-Linked Agammaglobulinemia
Y-Linked Disorder
Teen Escape (Ages 13 – 18)
NOTE: All children registered for the IDF National Conference Youth Program must complete a Youth Program Consent Form for each child at www.idfnationalconference.org/register.
Immune Deficiency Foundation - 2015 National Conference: Individual and Family Registration Form • Page 1 of 5
STEP I – General Meeting Registration, continued
Additional Guests or Family Members Attending:
Mr. / Ms. / Mrs. / Dr. First Name*:
Last Name*:
Address*:
Date of Birth (youth only):
City*:
State*:
Primary Phone*:
Postal Code*:
Primary Email*:
*Required Field
Relationship to Primary Registrant:
Spouse/Partner
Child
Parent/Caregiver
Sibling
Friend
Patient
Other Relative
Affected by a PIDD?
YES
NO If “yes”, please indicate diagnosis below:
Alpha One Antitrypsin Deficiency
Hyper IgM
Alpha One Genetic Empaxsoma
Hyper IgM Syndrome
Ataxia Telangiectasia
Hypoaglobulemia/Aspergillosis
Chronic Granulomatous Disease
Hypogammaglobulinemia
Chronic Lymphatic Leukemia
IgG Subclass Deficiency
Chronic Mucocutaeous Candidiasis
IgM Deficiency
Common Variable Immunodeficiency Disease
In-process of being diagnosed
Complement Deficiency
JOBS
DiGeorge Syndrome Anomoly
Leukocyte Adhesion Defect
Discoid Lupus
Lupus
Good Syndrome
Mannose Binding Lectin Deficiency
Hereditary Angiodema
Nemo
Hyper IgE
Neutropenia
This guest has special needs (ADA requirements, food allergy, etc). Please explain:
This guest will be participating in the following Youth Program on Friday & Saturday.
Childcare (Ages 6 months – 5 years)
Tween Scene (Ages 10 – 12)
Kids Club (Ages 6 – 9)
Other:
PNP Enzyme Deficiency
Selective IgA Deficiency
Severe Combined Immunodeficiency Disease
Specific Antibody Deficiency
Thrombocytopenia
Transient Hypogammaglobulinemia of Infancy
Unspecified Immune Deficiency
Wegener’s
Wiskott-Aldrich Syndrome
X-Linked Agammaglobulinemia
Y-Linked Disorder
Teen Escape (Ages 13 – 18)
NOTE: All children registered for the IDF National Conference Youth Program must complete a Youth Program Consent Form for each child at www.idfnationalconference.org/register.
Additional Guests or Family Members Attending:
Mr. / Ms. / Mrs. / Dr. First Name*:
Last Name*:
Address*:
Date of Birth (youth only):
City*:
State*:
Primary Phone*:
Postal Code*:
Primary Email*:
*Required Field
Relationship to Primary Registrant:
Spouse/Partner
Child
Parent/Caregiver
Sibling
Friend
Patient
Other Relative
Affected by a PIDD?
YES
NO If “yes”, please indicate diagnosis below:
Alpha One Antitrypsin Deficiency
Hyper IgM
Alpha One Genetic Empaxsoma
Hyper IgM Syndrome
Ataxia Telangiectasia
Hypoaglobulemia/Aspergillosis
Chronic Granulomatous Disease
Hypogammaglobulinemia
Chronic Lymphatic Leukemia
IgG Subclass Deficiency
Chronic Mucocutaeous Candidiasis
IgM Deficiency
Common Variable Immunodeficiency Disease
In-process of being diagnosed
Complement Deficiency
JOBS
DiGeorge Syndrome Anomoly
Leukocyte Adhesion Defect
Discoid Lupus
Lupus
Good Syndrome
Mannose Binding Lectin Deficiency
Hereditary Angiodema
Nemo
Hyper IgE
Neutropenia
This guest has special needs (ADA requirements, food allergy, etc). Please explain:
This guest will be participating in the following Youth Program on Friday & Saturday.
Childcare (Ages 6 months – 5 years)
Tween Scene (Ages 10 – 12)
Kids Club (Ages 6 – 9)
Other:
PNP Enzyme Deficiency
Selective IgA Deficiency
Severe Combined Immunodeficiency Disease
Specific Antibody Deficiency
Thrombocytopenia
Transient Hypogammaglobulinemia of Infancy
Unspecified Immune Deficiency
Wegener’s
Wiskott-Aldrich Syndrome
X-Linked Agammaglobulinemia
Y-Linked Disorder
Teen Escape (Ages 13 – 18)
NOTE: All children registered for the IDF National Conference Youth Program must complete a Youth Program Consent Form for each child at www.idfnationalconference.org/register.
Immune Deficiency Foundation - 2015 National Conference: Individual and Family Registration Form • Page 2 of 5
STEP II – Conference Session Registration
Please indicate the number of people from your group attending each event, including yourself.
Thursday, June 25th
12:00 PM – 5:00 PM
101A – Chronic Granulomatous Disease (CGD) Symposium
Child care needed during this session for:
qty of children, ages:
NOTE: This is separate from the IDF Youth Program and strictly
childcare. No programming available.
10:30 AM – 12:30 PM
It’s All About You! Specific Primary Immunodeficiency Disease Sessions
(Select One)
116 - Chronic Granulomatous Disease
(10:30 AM–2:30 PM, will break for lunch- indicate below)
117 - Common Variable Immune Deficiency
101B – Wiskott-Aldrich Syndrome Symposium
118 - DiGeorge Syndrome
Child care needed during this session for:
qty of children, ages:
119 - Hereditary Angioedema & Complement Deficiency
120 - Hyper IgE Syndrome
NOTE: This is separate from the IDF Youth Program and strictly
childcare. No programming available.
121 - Hyper IgM Syndrome
4:00 PM – 4:45 PM
102 – Introduction to Primary Immunodeficiency Diseases
123 - NEMO
5:00 PM – 5:45 PM
Speed Networking
104 - Adult Patients (50 years & up)
125 - X-linked Agammaglobulinemia
105 - Adult Patients (31-49 years)
106 - Young Adult Patients (19-30 years)
107 - Parents of Children (Birth-10 years)
108 - Parents of Children (11-15 years)
109 - Parents of Teens & Young Adults (16 years & up)
110 - Partners of Patients
6:00 PM – 7:30 PM
111 - Welcome to New Orleans Reception!
8:00 PM – 9:00 PM
112 - Young Adult Reception (19-30 years)
122 - IgG Subclass & Specific Antibody Deficiency
124 - Selective IgA Deficiency
126 - Severe Combined Immunodeficiency
(10:30 AM–2:30 PM, will break for lunch- indicate below)
127 - Wiskott-Aldrich Syndrome
(10:30 AM–2:30 PM, will break for lunch- indicate below)
170 - X-Linked Lymphoproliferative Disease: SAP and XIAP Deficiencies
12:30 PM – 2:30 PM
128 - Lunch
2:45 PM – 3:30 PM
Healthcare & Life Management Sessions (Select One)
129 - Antibiotic & Antifungal Therapy Sessions
130 - Managing Depression & Anxiety
131 - Autoimmunity & Immunodeficiency - What’s the Relationship?
Friday, June 26th
132 - The Connection Between Chronic Sinusitis & PI
7:30 AM – 9:00 AM
113 - Breakfast Symposium
Topic: New Discoveries & Future Treatments
7:30 AM – 9:00 AM
114 - Continental Breakfast
9:15 AM – 10:15 AM
115 - Opening Session
133 - Allergies & Primary Immunodeficiency Disease
134 - Dealing with Lung Issues
3:45 PM – 4:30 PM
Healthcare & Life Management Sessions (Select One)
135 - Autoimmunity & Immunodeficiency – What’s the Relationship? (Repeat)
136 - Antibiotic & Antifungal Therapy Sessions (Repeat)
137 - The Connection Between Chronic Sinusitis & PI (Repeat)
138 - Can I Really Ask That Questions? Getting the Answers You Need for Today’s World
139 - Managing Gastrointestinal Issues
140 - Health Insurance – Get the Facts
6:00 PM – 10:00 PM
141 - Childcare, Kids Club, ‘Tween Scene Dinner
142 - Teen Dinner
6:30 PM – 9:30 PM
143 - Zebra Gala - Adult Dinner and Awards
Immune Deficiency Foundation - 2015 National Conference: Individual and Family Registration Form • Page 3 of 5
STEP II – Conference Session Registration, continued
Saturday, June 27th
8:00 AM – 9:30 AM
145 - Continental Breakfast
8:00 AM – 9:30 AM
146 - Breakfast Symposium
Topic: Knocking Down the Barriers to Care
2:15 PM – 3:00 PM
Healthcare and Life Management Sessions (Select One)
157 - Genetic Counseling for Families
158 - Health Insurance – Get the Facts (Repeat)
159 - Practical Q&A on the Administration of Ig Therapy
9:45 AM – 11:00 AM
Healthcare & Life Management Sessions (Select One)
147 - Common Variable Immunodeficiency Frequently Asked Questions
160 - Parenting a Child Diagnosed with Health Issues
148 - Newborn Screening: SCID, Related T-Cell Lymphocyte
Deficiencies
3:15 PM – 4:00 PM
Healthcare and Life Management Sessions (Select One)
163 - Taking Care Ourselves: Women Getting it Done!
149 - Live! PI Connect Research Forum
11:15 AM – 12:00 PM
Healthcare and Life Management Sessions (Select One)
150 - Complementary & Alternative Medicine
161 - Young Adults – Life Beyond High School
162 - Immunological Testing
165 - For Men Only
151 - Managing Gastrointestinal Complications (Repeat)
166 - Practical Q&A on the Administration of Ig Therapy (Repeat)
152 - School Issues
153 - Gene Therapy
164 - Government Assistance Programs: Medicare, Medicaid and Social Security Income
167 - Can I Really Ask that Question? Getting the Answers You Need for Today’s World (Repeat)
154 - Immunoglobulin Therapy Overview
168 - Employment Issues
155 - Immunizations: Understanding the Risks and Benefits
169 - Nutrition and Immunity
12:15 PM – 2:15 PM
156 - Lunch
6:30 PM – 10:00 PM
176 - IDF Night at Mardi Gras World
STEP III – Hotel Room Reservations
Room Reservations are available for the conference nights (Wednesday, June 24-Saturday, June 27) at a group room rate of $199 + tax for single/double
occupancy and $219 for triple/quadruple occupancy at the Hyatt Regency New Orleans. IMPORTANT: When booking a room at the hotel please note that
number of guests refers to adults only, children under the age of 18 do not need to be entered as guests through the online system.
Maximum capacity is 4 guests per room.
Please note: You must book your hotel room at the Hyatt Regency-New Orleans to receive the discounted rates.
If you wish to extend your stay, the IDF group rate is available on limited number of rooms for Tuesday, June 23 and Sunday, June 28. There may also be
limited space available for these dates at the hotel standard rate.
In order to assure your guest room is booked for the IDF 2015 National Conference you must make your reservations prior to May 22, 2015.
Online reservations are available by going to www.primaryimmune.org and clicking on IDF 2015 National Conference where there is a link for Hyatt
reservations. If you wish, you can call Hyatt Reservations at 504-561-1234 and tell the reservation agent that you are with the IDF 2015 National
Conference and your reduced rate will go into effect. A major credit card is required to guarantee and hold your reservation. Your credit card will be
charged one room night when your reservation is made.
Immune Deficiency Foundation - 2015 National Conference: Individual and Family Registration Form • Page 4 of 5
STEP IV – Total Fees and Payment
Hyatt Regency Registration Fees:
For these rates, you MUST book a hotel reservation at the Hyatt
Regency-New Orleans.
On or before
April 30th
April 30th – June
6th
On Site after
June 6th (limited
space)
Individual
$125.00
$175.00
$325.00
Family (2-4)
$205.00
$255.00
$405.00
Registration Fees:
For those that are not staying at the Hyatt Regency-New Orleans.
On or before
April 30th
April 30th – June
6th
On Site after
June 6th (limited
space)
Individual
$325.00
$375.00
$425.00
Family (2-4)
$405.00
$455.00
$505.00
Additional family members ages 13 and above: $50.00 each
2-day Youth Program(s) Friday and Saturday: $60.00 per youth
REGISTRATION
1. Registration Fees (from above):
$
2. Additional Family Members age 13 and above:
Qty:
x $50 = $
3. Youth Program(s) - Childcare, Kids Club, Tween Scene, Teen Program:
Qty:
x $60 = $
4. General Contribution to IDF:
$
TOTAL REGISTRATION:
$
Payment Method:
Visa
Master Card
Discover
American Express
Name on Credit Card:
Credit Card Number:
Expiration Date:
Once your registration has been submitted and successfully processed, you will receive a confirmation email. If you have not received a confirmation email
within 24 hours of registration, please contact National Conference office via email at [email protected] or phone at 414.918.3022.
APPLY FOR A PARTIAL CONFERENCE SCHOLARSHIP
A limited number of partial scholarships are available based on financial need and are provided on a first-come, first-served basis. If you
are interested in a partial scholarship that will cover your hotel room only (Thursday, June 25, Friday, June 26 & Saturday, June 27), please
complete the online application found at: www.idfnationalconference.org.
The deadline for scholarship applications is March 19, 2015.
IDF will contact all scholarship applicants regarding their award status no later than March 30, 2015. You will be given a hotel
confirmation number to register for the conference at the time you are awarded a scholarship. If you do not register by April 15th,
your scholarship will be awarded to another applicant.
Immune Deficiency Foundation - 2015 National Conference: Individual and Family Registration Form • Page 5 of 5
IDF-1114-270
**Please note, registration and travel costs are not included in the partial scholarship. Due to the limited number of scholarships available,
preference will be given to first-time conference attendees.