MRKH Conference for Patients, Families, & Friends

MRKH Conference Registration Form

MRKH Conference For Teens & Thier Families, Saturday October 25th 2008, 8:00am-3:00pm, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115

To register for the conference, please fill out this form and click "Submit". If you are unable to submit the form online, please print it out, and complete it, and send it to the address at the bottom of this page.

We take your privacy seriously, and will only use the personal information that you enter to register you for the conference. We keep your information strictly confidential, and do not use it in any other way, or share it with any other group or person. Learn more about our Privacy Policy.

See schedule and detailed information about the days events.

Please enter your contact information. Items marked with an asterisk * are required.

Name*:

Date of Birth *:

Age*:

Address*:

City/Town*:

State*: Zip Code*:

Country:

Home Phone*: Cell Phone:

E-Mail Address*:

E-Mail Address*:
(Please enter the same email address twice, for spelling confirmation)

Please include the following attendee information:

I have been diagnosed with MRKH
I am a parent/guardian/family member or friend of a young woman who has been diagnosed with MRKH.

Names of family members or significant others who will be attending the conference:

Total number of people attending the conference *:

I will need assistance with finding hotel accommodations

Please let us know if you'd like to be on our MRKH mailing list.

Yes, I would like to receive announcements about future MRKH-related events at the Center for Young Women's Health

* Items marked with an asterisk are required.

When you click "Submit" we will receive your information, and register you. You may pay the registration fee when you arrive at the conference.
Please wait several seconds after you click.

If you prefer, you can print and email this form to:

The Center for Young Women's Health

333 Longwood Avenue, 5th Floor

Boston, MA 02115

USA

617-355-2994

If you have any questions, comments, or difficulties with this form, please contact us at phaedra.thomas@childrens.harvard.edu.

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