This section must be completed with registrants' complete name, age, and appropriate track for each attendee. Please print clearly; nametags will be provided.

Registrant's Name	Age	Type of Ichthyosis	Age Group
			Adult (18 and over) Teen (14-17) Pre-Teen (10-13) Child (1-9)
			Adult (18 and over) Teen (14-17) Pre-Teen (10-13) Child (1-9)
			Adult (18 and over) Teen (14-17) Pre-Teen (10-13) Child (1-9)
			Adult (18 and over) Teen (14-17) Pre-Teen (10-13) Child (1-9)
			Adult (18 and over) Teen (14-17) Pre-Teen (10-13) Child (1-9)
			Adult (18 and over) Teen (14-17) Pre-Teen (10-13) Child (1-9)

Section III – Clinical Screening Appointments

This is an opportunity to be seen by knowledgeable dermatologists to answer any questions or concerns that you may have. These appointments will take place throughout the day on Saturday, July 3. Your appointment will be assigned and posted at the registration table.

Name of Person for Appt.	Age	Sex	Type of Ichthyosis	Confirmed by a Dermatologist?
		Male Female		Yes No
		Male Female		Yes No

Section IV – Other

Do we have your permission to take photos during the conference?	Yes No
Do we have your permission to place photos of you and your family on our web site?	Yes No
Do we have your permission to include your contact information on a conference roster to be distributed to all registrants?	Yes No
Have you ever attended a conference before?	Yes No
Can you volunteer some time at the conference to help?	Yes No

Section V – Payment Information

The Foundation has received several sponsorships, which allows us to offer the discounted registration fees of $95 per adult and $50 per child. The actual cost per person at the conference is $150.00. Conference fees help offset the cost of food, beverages, room rental, supplies, etc.

Number of adults attending? (18 or over)		x $95.00 =	$
Number of children attending? (17 or under)		x $50.00 =	$
Additional Donation (optional)			$
Grand Total			$

  My check is enclosed, made payable to FIRST.
  Please charge my credit card:

• The conference will begin on Friday, July 2 at 2:00 pm CST and end on Sunday, July 4 at 12:00 pm CST .
  
• Breakfast, lunch and dinner will be provided on Saturday, July 3 and breakfast will be provided on Sunday, July 4.
  
• On Friday evening, July 2, there will be free time to visit the sites of Kansas City . Transportation will be available from the hotel to transport guests to the famed Country Club Plaza, an eating and shopping section of the city.
  
• Conference attendees are responsible for making their own room reservations at the Westin Crown Center . Call toll-free 888.627.8538, 24 hours a day.
  
• For those who are driving, there is a parking fee of $12.50 per night, with a $10.00 weekend max. For driving directions to the hotel, use www.mapquest.com or http://maps.yahoo.com/ . The hotel address is 1 Pershing Road , Kansas City , MO 64108 .
  
• KCI Shuttle provides transportation from the airport to the hotel. The cost for a one-way transport is $14.00 or $23.00 round trip. Simply report to the nearest KCI Shuttle ticket counter adjacent to most airline baggage claim areas.