PSM Registration France

2020 France Pachyonychia Congenita (PC) Patient Support Meeting (PSM)

June 4-6, 2020. Meeting will be held at the Golden Tulip Paris Airport CDG Roissy-en-France Hotel.

The meeting will begin on Thursday, June 4th with registration and an opening dinner that evening. The main presentations and discussions will take place on Friday, June 5th. Breakfast (included with hotel rooms), lunch and dinner will be provided on this day. Saturday, June 6th will begin with breakfast (included with hotel room), followed by meetings and conclude with a closing lunch.

For information on meeting fees, hotel registration and scholarships, please visit https://www.pachyonychia.org/2020psm/

NOTE: Once you submit the registration you will be redirected to Just Giving UK to pay the meeting fees. If you have PC and are attending a PSM for the first time, the meeting fees are waived for you and one family member. Please pay additional fees for any other family members or close the Just Giving UK window to finish.

1. Your contact information. *This question is required.

First Name

Last Name

Street Address

Apt/Suite/Office

City

State

Zip

Country

Email Address

Phone Number

Mobile Phone

2. Please tell us a little about yourself.

Age (if under 18)
Do you have PC?
Special dietary or other needs?

3. Have you (as a PCer or as a caregiver for someone with PC) submitted the International PC Research Registry (IPCRR) Consent Form, Questionnaire and photos to PC Project for the IPCRR?

4. Will this be the first time you have attended a PC Patient Support Meeting?

Please enter an 'other' value for this selection.

5. Why would you like to attend this Patient Support Meeting?

6. Please list any questions/topics you would like discussed at the Patient Support Meeting.

7. We hope you will be attending all sessions. If you are arriving late or leaving early, please mark which sessions you will be able to attend.

Thursday Night - Opening Dinner
Friday Morning Sessions
Friday Lunch
Friday Afternoon Sessions
Friday Dinner
Saturday Morning Sessions
Saturday Closing Luncheon
Select if you have children and they will attend Kids Program

8. Please provide information for those who will attend the meeting with you.

Space Cell	Name	Relationship	Age (if under 18)	Do they have PC?	Special dietary or other needs
Attendee 1	Attendee 1: Name	Attendee 1: Relationship	Attendee 1: Age (if under 18)	Attendee 1: Do they have PC?	Attendee 1: Special dietary or other needs
Attendee 2	Attendee 2: Name	Attendee 2: Relationship	Attendee 2: Age (if under 18)	Attendee 2: Do they have PC?	Attendee 2: Special dietary or other needs
Attendee 3	Attendee 3: Name	Attendee 3: Relationship	Attendee 3: Age (if under 18)	Attendee 3: Do they have PC?	Attendee 3: Special dietary or other needs
Attendee 4	Attendee 4: Name	Attendee 4: Relationship	Attendee 4: Age (if under 18)	Attendee 4: Do they have PC?	Attendee 4: Special dietary or other needs
Attendee 5	Attendee 5: Name	Attendee 5: Relationship	Attendee 5: Age (if under 18)	Attendee 5: Do they have PC?	Attendee 5: Special dietary or other needs
Attendee 6	Attendee 6: Name	Attendee 6: Relationship	Attendee 6: Age (if under 18)	Attendee 6: Do they have PC?	Attendee 6: Special dietary or other needs
Attendee 7	Attendee 7: Name	Attendee 7: Relationship	Attendee 7: Age (if under 18)	Attendee 7: Do they have PC?	Attendee 7: Special dietary or other needs

9. Additional comments.

10. Photo & Video Consent Form
- I hereby give my consent to have photographs and/or video taken of myself (or/and my child/children) which will be used by PC Project or PC Project Europe for educational, promotional and research purposes.
- I understand that these photograph(s) and/or video may appear in the public media, including print, internet and/or broadcast media for an indefinite period of time.
- I have been informed that these photograph(s) and/or video may be used more than once for educational and promotional purposes by PC Project.
- I understand my name and personal identifying information will not be associated with the photograph(s) and/or video without my additional written consent.
- I understand I have the right to withdraw the photograph(s) and/or video by a written request to PC Project. *This question is required.

Participant(s) Name(s) [Please list all attendees]
Signature (or guardian's signature for child) by typing the name
Date