WI BD Conference Registration Form

People in Your Party (first and last name)	Age of Children
Name:
Name:
Name:
Name:
Name:
Name:
Name:

Hemophilia Treatment Center	Madison Milwaukee La Crosse Green Bay* Other
*Green Bay HTC - If you attend HOC please contact the HTC prior registering for important information.

Is this your first time attending the conference? Yes No
If yes, would you like to be connected to a mentor family? yes no

Room Fee ($60 for each room you require)	$
Guest rooms with more than 4 people add $20	$
Registration fee ($25 per family)	$
An additional, non refundable registration fee of $50 is due per individual who is NOT an immediate family member (i.e. parent, non-adult sibling, spouse, significant other)
Total for non- immediate family members ($50 per person)	$

TOTAL	$

Cancellation Policy: Refunds will be given only if a cancellation is phoned into GLHF a minimum of 48 hours
(Thursday, June 9^th at 9am) before start of the weekend.

Method of Payment:

I will send GLHF a check by May 4, 2011

I will pay online with a Visa or Mastercard - Please make note of your total
After you submit this form click "Pay Online with Credit Card" link .

Patient of the Green Bay Hemophilia Treatment Center