2008 PBC Conference PBCers Shaping Our Future
Monday, June 23 thru Wednesday, June 25,
2008
Imperial Palace Hotel
& Casino
PRINTABLE FORM - PLEASE INCLUDE THIS FORM with your conference fee. Fee applies to ALL attending ANY PART of our
conference. ALL fees must be received by
June 10, 2008.
Mail form & fees to: PBCers Organization,
PBCer
or liver disease patient attending.
Please answer ALL questions that apply.
First & last name:
_____________________________________________________________________________
E-mail:
____________________________________________________ Disease stage if known: _____________
PBC____ Autoimmune
Hepatitis____ Hep C ____ PSC ____ Other liver
disease_______ US State you live in:
______ or Country outside
Date arriving
Are you staying at the
Would you like to participate in the Golf Challenge?
Yes ___ No ___ Walk
for the cure? Yes ___ No ___
Spouse attending conference with you (Skip if this question doesn't apply)
First & last name:
_____________________________________________________________________________
Would you like to participate in the Golf Challenge?
Yes ___ No ___ Walk
for the cure? Yes ___ No ___
Family member ____
friend ____ attending
conference with you (Skip if this
question doesn't apply)
First & last name:
_____________________________________________________________________________
E-mail:
_______________________________________________________________ US State you live in: ______ or Country
outside
Date arriving
Are you staying at
Would you like to participate in the Golf Challenge?
Yes ___ No ___ Walk
for the cure? Yes ___ No ___
Volunteers: To make sure our conference runs smoothly, we
need volunteers to help hand out programs/name tags, check in members at the
door, and greet our attendees. Will you
help by volunteering 1 - 2 hours
of your time during our conference?
Yes___ No ___ Will your spouse or traveling companion
volunteer 1 - 2 hours of his/her time? Yes ___ No ___
Auction: We ask our conference attendees to bring one
new gift or craft item for our fundraising auctions. Proceeds from our
auctions will be donated to the PBC Research and Education
Funds. Item can be brought to the conference or mailed to
our Las Vegas PBCer address prior to the
conference. Will you please donate a
gift or craft item? Yes ___ No ___
Amount Enclosed:
US funds only, check or money order made payable to PBCers Organization. No
conference fee prorations. Conference fee is fully refundable if written request is
received by May 18, 2008. Conference fee includes: 3 group lunches, 1
banquet dinner, coffee/tea refreshments, guest speaker meetings, PBCers
segments, family member segments,
registration
meet-n-greet, gratuity and tax. Mail this form & fees to: PBCers Organization,
Conference fee per person $130.00 received before April 15, 2008 #_____ X _____ = $_________
Conference fee per person $150.00 received after April 15, 2008 #_____ X _____ = $_________
Total amount
enclosed $_______________
Conference fee receipts will be sent to your e-mail address. If you DO NOT have
an e-mail address and would like a payment receipt, please include a stamped
self-addressed envelope with
your conference fee. Payment receipts will not be sent
without an e-mail address or SASE enclosed. If you cannot print this form to be
attached to your payment, please write answers on
another type of paper and include with your fees. We need all
of the above information to help us organize our conference.
If you have any other
questions, please e-mail conference@pbcers.org or call Linie at (281) 997-1516
Thank You,
Conference Organizing
Committee