Step 1 of 3 33% Are you applying for a Family Conference scholarship?YesNoI/We are applying for (check all that apply)* Registration Fees Lodging Deadline: Wednesday, February 28th Family Conference Scholarship funds are limited and are intended for families whose income level is less than $75,000. Each application will be ranked according to prior Family Conference attendance, Organization Involvement, and a brief statement on why you want to attend the Family Conference.Is this your first conference?*YesNoHow many conferences have you attended?*Please Select One123 or morePlease list any involvement with the NFED. For example: Participating in an event/fundraiser, Awareness Month, or serving on a committee.Why do you want to attend and how would your family benefit from attending the conference?*Please list circumstances that would prevent you from attending the conference.*The NFED operates 100% on private financial contributions. Our donors want to know the impact their gifts make on the work we do for our families. The best way to show our impact is to share stories from those that we've helped. As a recipient of this scholarship, your story could help us increase the amount of monies raised. We need you to write two to three paragraphs about your scholarship experience. You may choose to have your name published or remain anonymous. Please share your story here.Registration InformationRegistration: Adults (18 and older) $200 and Children (birth-17) $125 each. Registration: Adults (18 and older) $200, Children (birth-17) $125 and Family Liaisons fee is waived. I/We would like to register forFull ConferenceOne-DayI am a registered Family Liaison*YesNoHow many adults (18 and older) will be attending?*Please Select One12345How many children (birth-17) will be attending?*Please Select One0123456Total Number of AttendeesAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone Number*Phone Type*Please Select OneHomeMobileBusinessEmail Address* Please indicate the type of ectodermal dysplasia that affects your family.*Please Select OneAcro-Dermato-Ungual-Lacrimal-Tooth ADULT SyndromeAnkyloblepharon-ED Clefting AEC Syndrome Hay-WellsBook's SyndromeClouston SyndromeCoffin-Siris's SyndromeCranioectodermal DysplasiaDermatopathia Pigmentosa ReticulosisDyskeratosis CongenitaEctrodactyly-Ectodermal Dysplasia-Clefting EEC SyndromeEllis-van Creveld's SyndromeEpidermal NevusFocal Dermal Hypoplasia Syndrome GoltzFried's Tooth Nail SyndromeGAPOGorlin-Chaudhry-Moss' Syndrome Gorlin's SyndromeHallermann-Streiff's SyndromeHypohidrotic Ectodermal DysplasiaHypohidrotic Ectodermal Dysplasia ADHypohidrotic Ectodermal Dysplasia ARHypohidrotic Ectodermal Dysplasia IDHypohidrotic Ectodermal Dysplasia XLRHypomelanosis of Ito IPAIncontinentia PigmentiIsolated HypodontiaJohanson-Blizzard's SyndromeJorgenson's SyndromeKeratitis-Ichthyosis-Deafness KID SyndromeLacrimo-Auriculo-Dento-Digital LADD SyndromeMarshall's Syndrome IOculodentodigital ODD SyndromeOdontoonychodermal Dysplasia SyndromeOralfacialdigital OFD Syndrome II Mohr's SyndromePachyonychia CongenitaPalmoplantar Hyperkeratosis & AlopeciaPapillion-Lefevre's SyndromeRapp-Hodgkin's Syndrome RHSRothmund-Thomson's SyndromeSchopf-Schulz-Passarge's SyndromeSetleis SyndromeSuspected Ankyloblepharon-ED-Clefting AEC SyndromeSuspected Clouston'sSuspected Ectrodactyly-Ectodermal Dysplasia-CleftiSuspected Fried's Tooth Nail SyndromeSuspected Hypohidrotic Ectodermal DysplasiaSuspected Hypohidrotic Ectodermal Dysplasia ADSuspected Hypohidrotic Ectodermal Dysplasia ARSuspected Hypohidrotic Ectodermal Dysplasia XLRSuspected Rapp-Hodgkin's Syndrome RHSSuspected Witkop's Tooth Nail SyndromeTooth and NailTricho-dento-osseous TDO SyndromeTrichodental DysplasiaTrichoodontoonychial DysplasiaTrichorhinophalangael TRP Sydrome ITrichorhinophalangael TRP Sydrome I II Langer-GiediUnknownWitkop's Tooth Nail SyndromeOtherPlease specify type of ectodermal dysplasia*Are you a registered member of the NFED?*YesNoUnsureAttendeesName* First Last Date of Birth* MM DD YYYY If applicable, grade level for the 2018-2019 school year? Affected by Ectodermal Dysplasia T-Shirt Size*Please Select OneYouth X-Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Youth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-LargeWill be attending Kays' Kids Camp or Teens Program (determined by age)*YesNoPlease list any accommodations needed (vision or hearing impairment, autism, etc.)Needs dental evaluation*YesNoDietary Restrictions Dairy Allergy Gluten Free Kosher (no pork/beer) Kosher (meals from a Kosher Kitchen will have a surcharge) Nut Allergy Vegetarian Soft Foods Only Soy Allergy Poultry Allergy Vegan Seafood Allergy Other Please specify allergy*Name* First Last Date of Birth* MM DD YYYY If applicable, grade level for the 2018-2019 school year? Affected by Ectodermal Dysplasia T-Shirt Size*Please Select OneYouth X-Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Youth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-LargeWill be attending Kays' Kids Camp or Teens Program (determined by age)*YesNoPlease list any accommodations needed (vision or hearing impairment, autism, etc.)Needs dental evaluation*YesNoDietary Restrictions Dairy Allergy Gluten Free Kosher (no pork/beer) Kosher (meals from a Kosher Kitchen will have a surcharge) Nut Allergy Vegetarian Soft Foods Only Soy Allergy Poultry Allergy Vegan Seafood Allergy Other Please specify allergy*Name* First Last Date of Birth* MM DD YYYY If applicable, grade level for the 2018-2019 school year? Affected by Ectodermal Dysplasia T-Shirt Size*Please Select OneYouth X-Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Youth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-LargeWill be attending Kays' Kids Camp or Teens Program (determined by age)*YesNoPlease list any accommodations needed (vision or hearing impairment, autism, etc.)Needs dental evaluation*YesNoDietary Restrictions Dairy Allergy Gluten Free Kosher (no pork/beer) Kosher (meals from a Kosher Kitchen will have a surcharge) Nut Allergy Vegetarian Soft Foods Only Soy Allergy Poultry Allergy Vegan Seafood Allergy Other Please specify allergy*Name* First Last Date of Birth* MM DD YYYY If applicable, grade level for the 2018-2019 school year? Affected by Ectodermal Dysplasia T-Shirt Size*Please Select OneYouth X-Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Youth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-LargeWill be attending Kays' Kids Camp or Teens Program (determined by age)*YesNoPlease list any accommodations needed (vision or hearing impairment, autism, etc.)Needs dental evaluation*YesNoDietary Restrictions Dairy Allergy Gluten Free Kosher (no pork/beer) Kosher (meals from a Kosher Kitchen will have a surcharge) Nut Allergy Vegetarian Soft Foods Only Soy Allergy Poultry Allergy Vegan Seafood Allergy Other Please specify allergy*Name* First Last Date of Birth* MM DD YYYY If applicable, grade level for the 2018-2019 school year? Affected by Ectodermal Dysplasia T-Shirt Size*Please Select OneYouth X-Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Youth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-LargeWill be attending Kays' Kids Camp or Teens Program (determined by age)*YesNoPlease list any accommodations needed (vision or hearing impairment, autism, etc.)Needs dental evaluation*YesNoDietary Restrictions Dairy Allergy Gluten Free Kosher (no pork/beer) Kosher (meals from a Kosher Kitchen will have a surcharge) Nut Allergy Vegetarian Soft Foods Only Soy Allergy Poultry Allergy Vegan Seafood Allergy Other Please specify allergy*Name* First Last Date of Birth* MM DD YYYY If applicable, grade level for the 2018-2019 school year? Affected by Ectodermal Dysplasia T-Shirt Size*Please Select OneYouth X-Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Youth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-LargeWill be attending Kays' Kids Camp or Teens Program (determined by age)*YesNoPlease list any accommodations needed (vision or hearing impairment, autism, etc.)Needs dental evaluation*YesNoDietary Restrictions Dairy Allergy Gluten Free Kosher (no pork/beer) Kosher (meals from a Kosher Kitchen will have a surcharge) Nut Allergy Vegetarian Soft Foods Only Soy Allergy Poultry Allergy Vegan Seafood Allergy Other Please specify allergy*Name* First Last Date of Birth* MM DD YYYY If applicable, grade level for the 2018-2019 school year? Affected by Ectodermal Dysplasia T-Shirt Size*Please Select OneYouth X-Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Youth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-LargeWill be attending Kays' Kids Camp or Teens Program (determined by age)*YesNoPlease list any accommodations needed (vision or hearing impairment, autism, etc.)Needs dental evaluation*YesNoDietary Restrictions Dairy Allergy Gluten Free Kosher (no pork/beer) Kosher (meals from a Kosher Kitchen will have a surcharge) Nut Allergy Vegetarian Soft Foods Only Soy Allergy Poultry Allergy Vegan Seafood Allergy Other Please specify allergy*Name* First Last Date of Birth* MM DD YYYY If applicable, grade level for the 2018-2019 school year? Affected by Ectodermal Dysplasia T-Shirt Size*Please Select OneYouth X-Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Youth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-LargeWill be attending Kays' Kids Camp or Teens Program (determined by age)*YesNoPlease list any accommodations needed (vision or hearing impairment, autism, etc.)Needs dental evaluation*YesNoDietary Restrictions Dairy Allergy Gluten Free Kosher (no pork/beer) Kosher (meals from a Kosher Kitchen will have a surcharge) Nut Allergy Vegetarian Soft Foods Only Soy Allergy Poultry Allergy Vegan Seafood Allergy Other Please specify allergy*Name* First Last Date of Birth* MM DD YYYY If applicable, grade level for the 2018-2019 school year? Affected by Ectodermal Dysplasia T-Shirt Size*Please Select OneYouth X-Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Youth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-LargeWill be attending Kays' Kids Camp or Teens Program (determined by age)*YesNoPlease list any accommodations needed (vision or hearing impairment, autism, etc.)Needs dental evaluation*YesNoDietary Restrictions Dairy Allergy Gluten Free Kosher (no pork/beer) Kosher (meals from a Kosher Kitchen will have a surcharge) Nut Allergy Vegetarian Soft Foods Only Soy Allergy Poultry Allergy Vegan Seafood Allergy Other Please specify allergy*Name* First Last Date of Birth* MM DD YYYY If applicable, grade level for the 2018-2019 school year? Affected by Ectodermal Dysplasia T-Shirt Size*Please Select OneYouth X-Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Youth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-LargeWill be attending Kays' Kids Camp or Teens Program (determined by age)*YesNoPlease list any accommodations needed (vision or hearing impairment, autism, etc.)Needs dental evaluation*YesNoDietary Restrictions Dairy Allergy Gluten Free Kosher (no pork/beer) Kosher (meals from a Kosher Kitchen will have a surcharge) Nut Allergy Vegetarian Soft Foods Only Soy Allergy Poultry Allergy Vegan Seafood Allergy Other Please specify allergy*Name* First Last Date of Birth* MM DD YYYY If applicable, grade level for the 2018-2019 school year? Affected by Ectodermal Dysplasia T-Shirt Size*Please Select OneYouth X-Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)Youth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-LargeWill be attending Kays' Kids Camp or Teens Program (determined by age)*YesNoPlease list any accommodations needed (vision or hearing impairment, autism, etc.)Needs dental evaluation*YesNoDietary Restrictions Dairy Allergy Gluten Free Kosher (no pork/beer) Kosher (meals from a Kosher Kitchen will have a surcharge) Nut Allergy Vegetarian Soft Foods Only Soy Allergy Poultry Allergy Vegan Seafood Allergy Other Please specify allergy* ReleasesI give permission to the NFED to distribute my name and contact information to the other conference attendees.*YesNoI/we hereby give permission to the NFED to use and distribute (including but not limited to use in newsletters, guides, appeals, website, and reports), at their discretion, any photographs or video tapes taken at the 2019 NFED National Family Conference in which I or members of my family may be a part.*YesNoIn consideration of the acceptance of this registration entry, I/we the undersigned, assume full responsibility for any injury or accident which may occur while I/we am/are attending this conference. I/we hereby release and hold harmless the sponsors, promoters and all other persons and entities associated with this event from any and all personal injury or damage, whether it is caused by negligence of the sponsors, promoters or other persons or entity. Applications for minors will be accepted only if signed by a parent or guardian.Signature*Date* Registration Total $0.00 Adult Registrants* Price: $200.00 Quantity: Child Registrants* Price: $125.00 Quantity: Family Liaison Registrant* Price: $0.00 Quantity: Sole Family Liaison True Family Conference Refund Policy: If you are unable to attend the Family Conference, the NFED will refund your total conference registration fees less a $30 administration fee. There will be no refund allowed on or after July 1.Thanks for applying for a scholarship to attend our Family Conference. We do not need any billing information at this time. After submitting the application, we will notify you on April 1, 2019 via email about whether or not your application was approved.Thank you for registering to attend the Family Conference as a Family Liaison. We do not need any billing information for you since fees for you as a Liaison are waived. Billing InformationName* First Last Address* Use previous address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Payment MethodRegistration Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged.