National Conference June 1-3, 2012 - University of South Florida ± Tampa, Florida Open to young adults ages 18-30
REGISTRATION FORM
PARTICIPANT INFORMATION Last name:
First:
Middle:
Sex: *M
Age: *F
Birth date:
Street address:
Home phone #:
Cell phone #:
City:
State:
ZIP Code:
Email Address:
Your SWD Chapter or College/University:
Academic Year:
Insulin Pump? *Yes *No
Insulin/Pump Brand:
Insulin Type(s):
EMERGENCY CONTACT INFORMATION Name of Emergency Contact:
Relationship to you:
Home phone #:
Cell phone #:
In Case of Emergency I give permission to USF and/or Bringing Science Home and its personnel to give any medical care necessary to me and to share medical and other relevant information with other care providers. I give permission to Bringing Science Home and/or USF and personnel to transport and admit me to a clinic or hospital in the event that medical attention is necessary. The medical attention may include tests, X-rays, anesthesia, and/or surgery for medical or dental problems. I understand that Bringing Science Home or USF is not responsible for injury that may result from accidents, illnesses or other causes. Signature ________________________________________________________ Date ________________________
I give my permission for photo(s) taken of me during the conference to be published by SWD/Bringing Science Home and/or USF for program promotion. Signature ________________________________________________________ Date ________________________ Do you have special health or dietary needs (such as vegetarian, gluten-free or food allergies)? If so, please describe them: Please list any allergies and their symptoms? Do you use an epi-pen? Please describe any other special accommodations you will need during the conference. REGISTRATION & PAYMENT The Registration Fee includes meals, housing and activities Friday, June 1 ± Sunday, June 3. Conference and housing check-in is 3:30-6:00 pm on June 1st. Check-out is 2:30 pm on June 3rd. Double rooms will be provided in USF Residence Halls. If you have a roommate preference please indicate who you would like to room with: ______________________________________________________________. ³($5/< %,5'´ registration discount: Registration fee is only $40 if form and payment are received by March 1st. After March 1st the registration fee is $55.00. Early registration fee (open until March 1st) ««««««..«««««««««««« $40.00 __________________ OR Regular registration fee (if received March 2nd ± May 25th) «««««««.«««« __________________ Linen package (includes blanket, 2 sheets, 1 pillow, pillow case, 1 towel and 1 washcloth) «««««««««««« « __________________ USF Parking Permit (can be purchased in advance with this form or on-site)... $2.50/per day __________________ TOTAL PAYMENT ________________
Please mail this form and payment to: Bringing Science Home c/o Nicole Johnson University of South Florida 12901 Bruce B. Downs Blvd. MDC2 Tampa, Florida 33612-‐4799
For more information contact: Stephanie Melton at smelton@health.usf.edu / 813-‐396-‐2678 www.studentswithdiabetes.com
To connect with other SWD attendees: www.facebook.com/StudentsWithDiabetes
Checks may be made payable to USF/Bringing Science Home.
Once the registration form and payment has been received a confirmation email will be sent to you.