Exchange Registration Attendee InformationName:* First Last Badge Name*Please provide your first and last name as you would like it listed on your name badge. Complete Name Type of Attendee*Patient in Current/ Recent TreatmentPatient out of Treatment (focus on long-term effects)Caregiver/Family MemberSarcoma Subtype I am willing to have my subtype listed on my badge. Company Name (if applicable)Date of Birth* Date Format: MM slash DD slash YYYY Phone*Email*We will send your confirmation and other applicable correspondence to this email address. Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country How did you hear about the Exchange?Treatment LocationEmergency Contact:* First Last Phone Email AddressI plan to attend the following events: Friday Reception Saturday Breakfast Saturday Boxed Lunch Saturday Evening Event Sunday Breakfast Sunday Boxed Lunch Do you have dietary needs? (We will try our best to accommodate dietary restrictions.)*NoYes, I have the following dietary needsDietary Needs DescriptionFinancial HardshipSarcoma Exchange registration is FREE and we will provide meals, but participants will be responsible for their own travel and lodging costs to participate. A limited budget for those registrants with financial hardship is available for hotel reimbursement. Please check the box below if you would like an application following the event. I would like an application for hotel reimbursement emailed to me after the 2019 Sarcoma Exchange. Medical Emergencies: In the event of an illness, injury, or medical emergency arising during the event should the attendee be unable to make his/her own decisions, I hereby authorize and give my consent to the Event Director to secure from any accredited hospital, clinic and/ or physician any treatment deemed necessary for my immediate care. I agree that I will be fully responsible for payment of any and all medical services and treatment rendered to me including but not limited to medical transport, medications, treatment and hospitalization. Use of Personal Information: The personal information supplied in connection with this booking will be held by the Sarcoma Alliance as a record of attendees and parties expressing interest. By registering for this conference I agree that the Sarcoma Alliance may use that personal information to contact me by email, direct mail, telephone or fax to supply information relevant to this conference. Your information will not be shared outside of our organization. Consent to Use of Image: Further, I grant permission to the Sarcoma Alliance to use my name, voice and images of myself in any photographs, motion pictures, publications or any other print, videographic or electronic recording of this event for legitimate purposes. Cancellations or Postponements: The Sarcoma Alliance may at any time, with or without giving notice, in its absolute discretion and without giving any reason, change, cancel or postpone the conference, change its venue or any of the other published particulars, or withdraw any invitation to attend. In any case, neither the Sarcoma Alliance nor any of its directors, officers, employees, agents, members or representatives shall be liable for any loss, liability, damage, costs, or losses incurred, such as transportation costs, accommodations costs, or financial losses or expense suffered or incurred by any person, nor will they return any money paid to them in connection with the conference. Insurance: It is your responsibility to arrange appropriate insurance cover in connection with your attendance at the conference. The Sarcoma Alliance cannot be held liable for any loss, liability or damage to personal property. Disclaimer of Medical Advice: Views expressed by speakers, sponsors and/or exhibitors are their own. The Sarcoma Alliance cannot accept liability for any advice given, or views expressed, by any speaker, sponsor and/or exhibitor at the conference or in any material provided to you. You understand and acknowledge that you are responsible for your own medical care, treatment, and oversight. All of the content provided on the Sarcoma Alliance website and at the conference is for informational purposes only and DOES NOT CONSTITUTE THE PROVIDING OF MEDICAL ADVICE and is not intended to be a substitute for independent professional medical judgment, advice, diagnosis, or treatment. The content is not intended to establish a standard of care to be followed by you. You understand and acknowledge that you should always seek the advice of your physician or other qualified health provider with any questions or concerns you may have regarding your health. You also understand and acknowledge that you should never disregard or delay seeking medical advice relating to treatment or standard of care because of information contained in or transmitted at the conference. Changes to Terms and Conditions: We reserve the right at all time to change, amend, add or remove any of the above terms without prior notice. If one or more of the conditions outlined in these Terms & Conditions should be or become invalid, the remaining conditions will continue to be valid and apply. These Terms & Conditions apply to all participants of this event, including speakers, sponsors and exhibitors. Acknowledgment: By submitting this registration form, I acknowledge that I am the attendee and am 18 years of age or older, or that I am the parent or guardian for an attendee under the age of 18 and have the authority to register the minor and accept the terms and conditions on the minor’s behalf.Acceptance*By checking this box. I agree to the use of my personal information by the Sarcoma Alliance to contact me by email, direct mail, telephone or fax, in order to supply information about other conferences, fundraising, events and opportunities that the Sarcoma Alliance is planning and feel may be of interest to me. I have read and accept the terms and conditions stated above. Would you like to make a donation to the Sarcoma Alliance?After your Registration is submitted, you will be taken to PayPal to complete your donation. Yes, I would like to make a donation. Donation Amount Total $0.00 CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.