MLD Family Conference™

The Premier Family Resource for Metachromatic Leukodystrophy Information & Support

MLD Family Conference™ Registration
Wellington, New Zealand - Saturday February 26th, 2011

Click to see the Conference Overview or the Agenda

Online registration closes Friday February 18th.

Registration Instructions:
• Please fill out the form as best you can.
• Please let us know your arrival and departure dates even if you do not have travel reservations yet.
• Most families will arrive Saturday morning and depart after dinner Saturday night or Sunday morning. We start promptly at 13:00 Saturday.
• Please describe any special requests or dietary needs in the comments field.

Thanks! We look forward to seeing you in Wellington!

Information About You
First Name		Family (Last) Name
E-mail		re-enter E-mail
Address
Address 2
City
State/ Province		Postal Code
Country		Phone

Hotel Reservation & Attendees
Adults	All adult registrations include conference materials, Saturday break & dinner. STAYING AT HOTEL Yes, staying at the hotel ... room rate is $179 (rooming is not included in conference registration) No hotel room ... we're staying elsewhere or live locally. Additional non-MLD adults... in addition to yourself how many other non-MLD adults are attending with you? List names of ALL attending adults here so we can prepare name badges:
We register your non-MLD children/youth here ... MLD affected* are in the next section:*
Youth & Children (non-MLD)	youth or child eating ADULT MEALS (non-MLD) child eating CHILDREN's MEALS (non-MLD) Please list names and ages of all attending children & youth here so we can prepare their name badges:
Infants	<1 year old

MLD Affected Family Member(s) - please list even if they are not attending

MLD Family Member #1

Name:

Age:

MLD Family Member #2

Name:

Age:

attending?

Yes

Unsure

attending?

Yes

Unsure

wheelchair?

Fixed

Folding

wheelchair?

Fixed

Folding

Birthday

Month	Day	Year

Birthday

Month	Day	Year

If Deceased, date of death

Month	Day	Year

If Deceased, date of death

Month	Day	Year

Therapy?

eats regular meals?

Yes - adult size
Yes - child size
No

eats regular meals?

Yes - adult size
Yes - child size
No

Travel Arrangements

Travel Dates

Arrival:	Conference starts 13:00 Saturday the 26th.
Departure:	Conference ends 20:00 Saturday the 26th.

The hotel has extended our conference room rate of $179 per night if you wish to arrive earlier or depart later.

Transportation

Rail

Fly

Drive

Travel Details

Please supply rail/air travel information if available:
Arrival Flight/Train #: time: Airline:
Depart Flight/Train #: time: Airline:

Comments -
(if you need scholarship help or have special dietary needs please indicate this here)

Please consider a donation to the MLD Family Conference scholarship fund to assist families that may not otherwise be able to attend the conference. Scholarship donations are tax deductible.

Yes

Would you like to add a modest 3% to your conference registration fees to cover our credit card transaction costs?

To make sure you are human and not a spammer, please enter the answer to the simple math problem above here:

<-- Click here to submit your registration and proceed to the payment screen.

Please note: Registrations are not complete until the registration fees are paid and all registrations are subject to the guidelines on the Overview page.