SpringFest 2008 Registration

*** Space for this event is limited. ***
This event is available to people with a bleeding disorder and their immediate family.

For registration questions please call: 1-800-482-3041

Contact Information

Adults Attending

Name	Interested in participating in the Sunday Health and Wellness Therapies?	Interested in volunteering with child care infant-4 years old on Saturday?





Who in your family has a bleeding disorder and what type?

Children Attending - Infant to 4 years old ONLY

Hotel and Special Events Registration

FIRM Registration Deadline: March 24, 2008

* The only way to guarantee your reservation is to register by this date. *

	Saturday, April 13	$95 / Family of Four People $25 / Each Additional Adult $10 / Each Additional Child (3 yrs & up) (2 yrs and under are free)
	Double room, program and meals, including Sunday Breakfast (Covers Up to Two Adults and Two Children)
	Programming - family of four @95 = $ Additional Adults @25 = $ Additional Children @10 = $

Total Amount: $

** Special Needs: (Refrigerators are available in every room)**

Crib Smoking Rollaway Bed Wheelchair Accessible Other

Will anyone require a vegetarian meal for lunch and dinner?
Name(s):

Important: Your are responsible for incidental costs (phone, room service, movies etc.) that are charged to your room. You will be asked to present a credit card or a refundable deposit at registration to cover these costs.

Payment Information

** Financial Assistance is available based on need **

* = Required Field
* Name:
* Address:
* City:
* State:
* Zip Code:
* County of Residence:
* Email:
Phone:

	Friday, April 12	$125 / Room
	Optional Friday night stay (reduced rate per room) You are responsible for paying for Friday night.
	Rooms @$125 = $

* Please specify your credit card information*
Total:	0
* Credit Card:	Visa MasterCard American Express Discover
* Card number:
* Expires:
* Name on Card:	First:
	Last:

* Billing Address:
* City:
* State:
* Zip Code:

Adult responsible for children:
Hematologist of child with BD:
Hematologist phone number:

Name	Age	Bleeding Disorder (Please indicate if none)

	Saturday Program ONLY	$25 / Person
	Individuals @$25 = $