2020 Virtual FOP Family Gathering

Basic Information

Please note:

This registration form is inteded for use by individuals with FOP, family members and friends. If you are a biotech, pharma or other corporate entity please contact Michelle Davis, IFOPA executive director, at together@ifopa.org for the link to register.

If you are a health care professional who cares for an individual with FOP please register here: https://www.ifopa.org/local_health_care_providers

This form can be translated using the button in the upper left-hand corner.

Each attendee registered in this form must have a unique email address. The same email address cannot be used twice for different attendees. If you need assistance setting up an email for additional people in your group to attend please contact Hope Newport, Family Services Manager at hope.newport@ifopa.org

This form must be completed by individuals over the age of 17. All youth participants must be registered by a parent/guardian.

Name*

First Name

Last Name

Email*

Country Code for Phone Number

Phone

Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Please share the name of the individual with FOP who you are connected to.

Virtual Event Participation

I plan to join the Virtual Family Gathering from the following device*

Smartphone Tablet Laptop/Desktop Computer

Does your computer/laptop have a microphone?

Yes No

Does your computer/laptop have a camera?

Yes No

Please check which days of virtual Family Gathering you plan to attend?*

Friday, November 20 Saturday, November 21 Sunday, November 22

Please rank your top 3 choices for which of the following breakouts topics (taking place on Saturday, November 21) you would be most interested in hearing about (with 1 being your top choice.)

Please rank your top 3 choices for which of the following breakouts topics (taking place on Saturday, November 21) you would be most interested in hearing about (with 1 being your top choice.)
	1	2	3
Adaptive Tool Use and Home Adaptions Problem Solving	Please rank your top 3 choices for which of the following breakouts topics (taking place on Saturday, November 21) you would be most interested in hearing about (with 1 being your top choice.): Adaptive Tool Use and Home Adaptions Problem Solving (1)	Adaptive Tool Use and Home Adaptions Problem Solving (2)	Adaptive Tool Use and Home Adaptions Problem Solving (3)
Implementing Self Care & Protecting Your Emotional Health	Implementing Self Care & Protecting Your Emotional Health (1)	Implementing Self Care & Protecting Your Emotional Health (2)	Implementing Self Care & Protecting Your Emotional Health (3)
Virtual Fundraising for the IFOPA	Virtual Fundraising for the IFOPA (1)	Virtual Fundraising for the IFOPA (2)	Virtual Fundraising for the IFOPA (3)
FOP Management and Resources for Children	FOP Management and Resources for Children (1)	FOP Management and Resources for Children (2)	FOP Management and Resources for Children (3)
FOP Management and Resources for Teens and Adults in their 20's	FOP Management and Resources for Teens and Adults in their 20's (1)	FOP Management and Resources for Teens and Adults in their 20's (2)	FOP Management and Resources for Teens and Adults in their 20's (3)
FOP Management and Resources for Adults over the Age of 30	FOP Management and Resources for Adults over the Age of 30 (1)	FOP Management and Resources for Adults over the Age of 30 (2)	FOP Management and Resources for Adults over the Age of 30 (3)

Please note, translation for these smaller group discussions is only available on laptops and desktop computers (not smartphones or tablets.)

Will you require translation services to participate in the Family Gathering?*

Yes No

Translation Preferences

Register Additional Attendees

Would you like to register any additional attendees?*

Yes No

You can register 1 additional adult and up to 3 additional youth attendees (under the age of 18.)

I would like to register

an adult attendee an attendee under the age of 18

Additional Attendee(s) (Adults)

Name*

First Name

Last Name

Email*

Virtual Event Participation (Additional Attendee)

This attendee plans to join the virtual family gathering from the following device*

Smartphone Tablet Laptop/Desktop Computer

Does this attendees computer/laptop have a microphone?

Yes No

Does your computer/laptop have a camera?

Yes No

Please check which days of virtual Family Gathering you plan to attend?*

Friday, November 20 Saturday, November 21 Sunday, November 22

Please rank your top 3 choices for which of the following breakouts topics (taking place on Saturday, Nov 21) you would be most interested in hearing about (with 1 being your top choice.)

Please rank your top 3 choices for which of the following breakouts topics (taking place on Saturday, Nov 21) you would be most interested in hearing about (with 1 being your top choice.)
	1	2	3
Adaptive Tool Use and Home Adaptions Problem Solving	Please rank your top 3 choices for which of the following breakouts topics (taking place on Saturday, Nov 21) you would be most interested in hearing about (with 1 being your top choice.): Adaptive Tool Use and Home Adaptions Problem Solving (1)	Adaptive Tool Use and Home Adaptions Problem Solving (2)	Adaptive Tool Use and Home Adaptions Problem Solving (3)
Implementing Self Care & Protecting Your Emotional Health	Implementing Self Care & Protecting Your Emotional Health (1)	Implementing Self Care & Protecting Your Emotional Health (2)	Implementing Self Care & Protecting Your Emotional Health (3)
Virtual Fundraising for the IFOPA	Virtual Fundraising for the IFOPA (1)	Virtual Fundraising for the IFOPA (2)	Virtual Fundraising for the IFOPA (3)
FOP Management and Resources for Children	FOP Management and Resources for Children (1)	FOP Management and Resources for Children (2)	FOP Management and Resources for Children (3)
FOP Management and Resources for Teens and Adults in their 20s	FOP Management and Resources for Teens and Adults in their 20s (1)	FOP Management and Resources for Teens and Adults in their 20s (2)	FOP Management and Resources for Teens and Adults in their 20s (3)
FOP Management and Resources for Adults over the Age of 30	FOP Management and Resources for Adults over the Age of 30 (1)	FOP Management and Resources for Adults over the Age of 30 (2)	FOP Management and Resources for Adults over the Age of 30 (3)

Please note, translation for these smaller group discussions is only available on laptops and desktop computers (not smartphones or tablets.)

Will this attendee require translation services to participate in the Family Gathering? *

Yes No

Translation Preferences

Register Youth Attendees

Would you like to register any youth attendees?*

Yes No

Additional Attendee(s) Youth

Please provide the following information for any participants you are registering that are under the age of 18. Please note, if you want your child to participate in activities at the same time you are they will need their own login information. The email address provided for youth attendees must be different than the email address used to register any adult attendees.

Name*

First Name

Last Name

Email*

This attendee is *

a child/teen with FOP a sibling

This attendee plans to join the virtual family gathering from the following device:*

Smartphone Tablet Laptop/Desktop Computer

Does this attendees computer/laptop have a microphone?

Yes No

Does this attendees computer/laptop have a camera?

Yes No

Please provide the age and any pertinent information you would like to share about your child with FOP or sibling listed above. *

Does this attendee have the same translation needs as the adult(s) listed above? If no, please explain.*

Would you like to register a second participant under the age of 18?

Yes No

Additional Youth Attendee

Name*

First Name

Last Name

Email*

This attendee is *

a child/teen with FOP a sibling

This attendee plans to join the virtual family gathering from the following device:*

Smartphone Tablet Laptop/Desktop Computer

Does this attendees computer/laptop have a camera?

Yes No

Does this attendees computer/laptop have a microphone?

Yes No

Please provide the age and any pertinent information you would like to share about your child with FOP or sibling listed above.*

Would you like to register a third participant under the age of 18? *

Yes No

Additional Youth Attendee

Please provide the following information for any participants you are registering that are under the age of 18. Please note, if you want your child to participate in activities at the same time you are they will need their own login information. The email address provided for youth attendees must be different than the email address used to register any adult attendees.

Name*

First Name

Last Name

Email*

This attendee is

a child/teen with FOP a sibling

This attendee plans to join the family gathering from the following device:*

Smartphone Tablet Laptop/Desktop Computer

Does this attendees computer/laptop have a microphone?

Yes No

Does this attendees computer/laptop have a camera?

Yes No

Please provide the age and any pertinent information you would like to share about your child with FOP or sibling listed above. *

Does this attendee have the same translation needs as the adult(s) listed above? If no, please explain.*

Questions

Please submit any specific questions you have for our speakers. Examples include: FOP Medical Experts Panel, FOP Clinical Trials Panel, Pain Management Panel, Dental and Anesthesia Experts Panel.

Attendees will have additional opportunities to submit questions leading up to and on the day of the event for all presentations.