Spina Bifida Association of Greater New England · 2024

Contact Information

Name *

Prefix

First Name

Last Name

Suffix

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Email *

Verify Email *

Phone (cell preferred) *

Attendee Information

Total Number in Group *

Total Number in Group

Name of person with Spina Bifida *

Birthdate of person with Spina Bifida *

(mm/dd/yyyy)

Does anyone in your party use? *

Braces/Crutches

Electric Wheelchair

Manual Wheelchair

None of the above

Does anyone in your party require an interpreter?

ASL

Portuguese

Spanish

Other - please contact me

Babysitting

Babysitting will be provided for children ages birth - 5th grade. Please provide the names(s) and ages(s) of children requiring babysitting.

Name(s) and age(s) of children requiring Babysitting

Teen Programming

Please provide the name(s) and age(s) of children for Teen Programming.

Name(s) and age(s) of children for Teen Programming

Young Adults

Name(s) and ages(s) of young adults, 18-22

Dietary Restrictions / Allergies

Does anyone in your party require/have dietary restrictions or allergies? Please describe below.

Dietary restrictions or allergies?

Photo Release

I agree that SBAGNE may use photos of me and/or my minor children from Conference for website, email. Annual Report and social media purposes.

Photo Release *

Yes

No

Liability Waiver Acknowledgement

Please review the following text and acknowledge that you have read and agree.

(We), as parent(s) or guardian(s) of the minor, do hereby, for my/our self, heirs, executors and administrators, remise, release and forever discharge the Spina Bifida Association of Greater New England, all of the officers, employees, and agents of each of the foregoing acting officially otherwise, from any and all claims, demands, actions or causes of action on account of my/our self(ves) and my minor child. I hereby certify that the minor is my/our child.

In case of accident, permission is granted for emergency treatment to be administered. It is further understood that I/we will assume full responsibility for any such action, including payment of costs. I/we hereby advise that any allergies or special considerations for myself and the above named minor has been disclosed during this registration process.

Liability Waiver Acknowledgement *

Yes

Conference Registration Fee

Please select your Registration Fee option below. If you would like to make an optional donation to provide a scholarship for a low-income family, add your donation to your registration fee total and enter in the empty Registration Fee field below. For example you are an Individual and want to donate a Family fee you would enter ($25 + $100 = $125 total in the empty Registration Fee field only).

Registration Fee *

$25 - Individual

$50 - Couple

$100 - Family

$0 - I need to apply for a scholarship

$

Hotel Reservations

Hotel reservations are separate from the Conference Registration Fee and are not included. You will receive the link for the reservations in your confirmation email.

2024 - SBAGNE Family Conference