NAF 2018 Regist Form

12th Annual "Neuropathy Action Awareness Day"

Friday, June 22, 2018
Intercontinental Hotel, Los Angeles

Please complete this registration form and the payment page. Your registration will be acknowledged by email. THANK YOU! (REGISTER BEFORE JUNE 11 TO AVOID A $50 CHARGE)

Please check off which events you will attend:
*

I am a neuropathy patient or caretaker and will attend the Event & Luncheon: $25 per person

I am NOT a neuropathy patient or caretaker and will attend the Event & Luncheon: $125 per person

I cannot attend in person but will watch on the Internet via Live Stream: Free

*Please provide the information below: (Type as you wish your name to appear in print)

First Name *

Middle

Last Name *

Company / Organization

Address *

City *

State *

Zip/Postal Code *

Country *

Email Address: *

Phone * 🛈

In addition, the following guests will attend:

	Guest(s) of neuropathy patient/caretaker: $25
	Guest(s) of non-neuropathy patient/caretaker: $150

Guest Name(s)

I would like to make a contribution in the amount of:

General Comments:

Code:

Click "Continue" below to review your order and payment options.

Cancellation Policy: You may cancel or change your registration up to 7 days prior to the meeting (on or before June 15, 2018) without penalty. You will receive a full refund promptly. Cancellations for any reason received after June 15, 2018 cannot be refunded. No shows are not refundable.

NEED HELP: Please call or email us at (877) 512-7262 (info@neuropathyaction.org) for assistance. Thank you.