Alfas en Camino - REGISTRATION FORM – NON SPANISH PARTICIPANTS

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Alfas en Camino - REGISTRATION FORM – NON SPANISH PARTICIPANTS

GENERAL

Surname:

First name:

ID / PASSPORT:

Full address:

Telephone number:

E-mail:

I am...

I have Alpha-1 Antitrypsin Deficiency

I am a family member or companion

Other:

Clear selection

Do you belong to a Patient Association or entity?

No, I am not a member of any patient association

I am a member of Alfa Spain, or direct family member of partner

I am a member of another patient association

Clear selection

If you answered "other" to the previous question, specify which entity you are part of:

Do you have lung disease?

Yes, I have COPD (emphysema, bronchitis)

Yes, I suffer from asthma

Yes, I have a lung transplant

Yes, I suffer from other diseases

If you answered "other" to the previous question, specify which disease you suffer from:

If you use oxygen, clearly specify the needs: equipment, O2 flow needed, hours/day, etc.

Do you have liver disease?

Yes, I have liver disease

Yes, I have a liver transplant

Clear selection

Are you traveling alone or with a companion/s?

I travel alone

I travel accompanied by (specify name/s)

I travel accompanying (specify name)

Clear selection

Specify the name of the person(s) accompanying you or whom you are accompanying

ACCOMMODATION

Will you share a room?

Yes, I will share a room with my partner (indicate name in the next section)

Yes, I will share a room with a companion (indicate name in the next section)

Yes, I can share a room with whoever the Organization designates

No, I do not want to share a room

Clear selection

Specify the name of the person with whom you will share your room:

DIET

Are you allergic to any food? (specify)

Do you have any special dietary needs? (vegetarian, vegan, other, specify)

AT THE CAMINO

Indicate which group you wish to enroll in (before answering, check the details about the groups following this link or in the REGISTRATION section of the web camino.alfa1.org.es)

Group 1

Group 2

Group 3

Clear selection

PHYSICAL PREPARATION

The Association is organizing a virtual program to guide the participants in the physical preparation necessary to complete the Camino, developed by a team of physiotherapists. We recommend everyone to follow it, especially participants with lung disease.

Are you iterested in following the fitness program?

Yes, I want to receive information to participate

No, I don't want to participate

Clear selection

REMARKS

Please let us know here of any other questions about your participation that you think we should be aware of.

Personal data processing authorization

By submitting this form you are authorizing the Alfa-1 Association of Spain, CIF G47429865 to process your personal data for the sole purpose of managing the relationships arising from the activity in which you enroll. You can exercise the corresponding rights of rectification, deletion or limitation of treatment, by means of a request addressed to the Alfa-1 Association of Spain, rúa Xosé Chao Rego, 8 – bajo, 15705 Santiago de Compostela (A Coruña) or at the email address: info@alfa1.org.es, as well as direct claims derived from the treatment to the AEPD. You can consult more information about our Privacy Policy at: https://alfa1.org.es/politica-de-privacidad/

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