2019 Annual ULF Conference - Family Your Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Phone*Family Members (Please include all names and ages of attendees. We will use this information for meal planning purposes, and determine attendance for youth and teen programs.)First NameLast NameAge If you are bringing a child/children with you, a daycare room will be provided during the hours of the sessions for children who are 12 years old and younger.Yes, I would like my child/children to attend daycare during sessions.No, my child/children will be sitting in the sessions with me.**Children must be collected from the daycare room to attend meal times with parents.**If you are bringing a teen (age 13 - 18) with you, will they participate in the Teen Program?Yes, my teen(s) will participate in the Teen Program.No, my teen(s) will be sitting in the sessions with me.**Children must be collected from the daycare room to attend meal times with parents.Type of LeukodystrophyMeal Planning:*Please check all appropriate boxes below for meal planning purposes. The cost of all meals is included in your registration fee. Select All Dinner - Thursday, June 27 Breakfast - Friday, June 28 Lunch - Friday, June 28 Dinner - Friday, June 28 Breakfast - Saturday, June 29 Lunch - Saturday, June 29 Dinner - Saturday, June 29 Breakfast - Sunday, June 30 Special Meal Needs: Vegetarian Gluten-Free Kosher Special Meal Details:Please specify how many of each type of meal is needed. Be sure to be as clear as possible.Are you a current ULF member?*YesNo2019 Conference T-Shirt DesignYes, my first name plus my family's first namesYes, but only the adult first namesNo, thank youWe are designing a special t-shirt for the 2019 conference! We would like to include all of the attendee's (adults, kids, and medical professionals) first names on the back of the t-shirt. We will make sure that family names are grouped together. Would you like your name(s) to be included?I would like to purchase a ULF Family Membership now to save money and register at the discounted member rate. Only one membership needed per family! Price: $50.00 Quantity: # of ULF Member Adults Price: $25.00 Quantity: # of Non-Member Adults Price: $100.00 Quantity: # of Teens Price: $0.00 Quantity: # of Children Price: $0.00 Quantity: Total $0.00 EmailThis field is for validation purposes and should be left unchanged.