We The Patients Week on Capitol Hill
Registration

June 11 - 13, 2024
Washington, D.C.

First name*

Last name*

Email*

Mobile phone number*

Phone number

Street address*

Address Line 2

City*

State/Region*

Postal code*

Company name

Birth Year*

How would you describe your role? Check all that apply*

Advocate

Patient

Caregiver

Industry Representative

Let us know if you are a: (Check all that apply)*

Have you attended a Fly-In or Hill Day before?*

Yes

Do you require assistance with your condition in order to participate in We The Patient events? If so, please explain.

For Hill meetings, what pace would suit you?*

Fast Pace

A more slow pace

Name as you would like it to appear on your badge.*

Emergency Contact Full Name*

Emergency Contact Phone Number*

Photo and Image Release

I grant to Patients Rising Now, its representatives and employees the right to take photographs and videos of me and my property in connection with the We The Patients Fly-In event. I authorize Patients Rising Now, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Patients Rising Now may use such photographs and videos of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

I have read, fully understand, and agree to the statement above.*

We The Patients Week on Capitol HillRegistration

June 11 - 13, 2024Washington, D.C.

Photo and Image Release

Communication Permissions

We The Patients Week on Capitol Hill
Registration

June 11 - 13, 2024
Washington, D.C.