#MedicalNutritionEquityNow Hill Day Registration Confirmation

Please fill out this form once for EACH attendeed at the #MedicalNutritionEquityNow Hill Day. For children, use the voting address and email address of their parent/guardian.

Attendees's Name*

First Last

Please confirm the following:*

Yes, I plan to attend the #MedicalNutritionNow Hill Day
No, my plans have changed and I am unable to attend

Is the attendee a minor (under 18 years old)*

No
Yes

Name of Parent or Accompanying Guardian*

Attendee's Age*

Attendee's Email Address*

Attendee's Email Address (if applicable)

Attendee's Cell Phone Number*

Attendee's Cell Phone Number (if applicable)

Attendee's Voting Address*

Street Address Address Line 2 City State ZIP Code

Attendee's Voting Address

Street Address Address Line 2 City State ZIP Code

I will be staying at the following hotel*

I will be arriving in time for the 3pm required training session at the Capitol Skyline Hotel on Monday, May 6*

Yes
No

Please indicate when you will arrive*

I will be leaving DC after 6:30pm on Tuesday, May 7*

Yes
No

Please indicate when you will be leaving DC*

I understand that by submitting this form I am cancelling my registration for the #MedicalNutritionEquityNow Hill Day*

Yes

If you registered for others and need to cancel their registrations as well, please enter their names below.

I understand that the Patients & Providers for Medical Nutrition Equity Coalition will be booking all of my meetings on Tuesday, May 7 and I should attend only my assigned meetings.*

I agree

Please include any additional comments including whether the attendee is a child, and/or has accessibility requirements.