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Basic Information
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.
First Name
*
Last Name
*
Email Address
*
Mobile (with country code)
*
Two-step verification is required in order to access the event. A text will be sent to the phone number and email you provided above with a verification code to login. *Please be sure to include your country code if you do not live in the United States.
Address
Address Line 1
Address Line 2
City
State/Province
ZIP / Postal
Country
*
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People\'s Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People\'s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Republic of Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Please select the choice that best describes your connection to the FOP community.
*
I am an individual living with FOP
I am the mother of an individual living with FOP
I am the father of an individual living with FOP
I am the significant other/spouse of an individual living with FOP
I am the sibling of an individual living with FOP
I am the extended family member of an individual living with FOP
I am a family friend of an individual living with FOP
I am a family member of an individual with FOP who has passed away
If you are a physician or researcher or don't see your relationship listed please contact Hope Newport, Family Services Manager at hope.newport@ifopa.org.
Please share the name of the individual with FOP who you are connected to.
Are you in contact with the FOP national organization in your country?
Yes
No, I am not contact with the FOP National Organization in my country
I am not aware of a FOP National Organization in my country
Virtual Event Participation
I plan to join the Virtual Family Gathering from the following device
Smartphone
Tablet
Laptop/Desktop Computer
Please note if you are interested in participating in either of the pre-event meetings taking place throughout the week of October 3.
Attendee Meet and Greet/IFOPA Program Trivia with Staff
Ready, Set, Success: A Family Gathering Orientation
Meet the FOP Clinical Trial Sponsors
Translation Preferences
Will you require translation services to participate in the Family Gathering?
*
Yes
No
What language would it be most helpful for you to have the Family Gathering environment and presentations translated into? Options include:
Arabic
Bengali
Chinese (Simplified)
Chinese (Traditional)
Dutch
French
German
Hindi
Indonesian
Italian
Japanese
Korean
Polish
Portuguese
Romanian
Russian
Spanish
Swedish
Tamil
Vietnamese
Other:
Other Value
Questions
Please submit any specific questions you have for our speakers. Examples include: FOP Medical Experts Panel, FOP Clinical Trials Panel, Ear, Nose and Throat And FOP or Dentistry and FOP sessions.
Attendees will have additional opportunities to submit questions leading up to and on the day of the event for all presentations.
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