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2023 MSMDS Conference Registration
Please complete this form whether you plan on attending in person or joining us online.
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Email
*
Your email
Name
Your answer
Address
Your answer
Phone Number
Your answer
How are you planning on attending the conference?
In-Person
Virtual
Undetermined
Are you a clinician, patient, family member, or volunteer?
Family Member
Patient
Clinician
Researcher
Volunteer
Do you or a family member have MSMDS?
Yes
No
Clear selection
For clinicians, do you currently treat patients with the MSMDS diagnosis?
Yes
No
Maybe
Clear selection
Are you planning on attending a select day or the the entire event?
Friday
Saturday
Sunday
Entire Event
Will you require translation services? If yes, please list your desired language.
Your answer
Would you like to hear future updates from ACTA2 Alliance?
Yes
No
Clear selection
The following questions are just for those attending in person.
If you are planning on attending virtually, thank you so much for registering!
We will be sending out detailed information about the virtual program in April.
If a patient or family member, please name those attending with you.
Your answer
If you would like childcare during the conference, please list each child and their age below.
Your answer
We will be hosting a Family and Physician Dinner on Friday night. If you'd like to attend, please indicate the number of adults and children who will be attending. (Open to all. Pricing TBD)
Your answer
Do you have any specific dietary allergies or preferences we can accommodate throughout the weekend?
Your answer
For families, would you be open to or interested in sharing your story and journey publicly with ACTA2 with our community during the conference?
Yes
No
Maybe
Clear selection
A copy of your responses will be emailed to the address you provided.
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