Family/Individual Registration Form

Registration Form for Action Duchenne Members, Non-Members, Families, Children, Living with Duchenne and Carers

PLEASE NOTE: If you are registering for the conference as either of the following, please click here to register for your tickets:

Pharmaceutical Company
Other Professional
Postgraduate Student
Voluntary Sector Organisation
Speaker

If you are an Action Duchenne Member, Non-Member, Family Member, Child or Carer please continue to register below.

Please select how many tickets in total you require below. Tickets must be booked for all persons attending including children and PA/Professional Carers.

Tick this button if you are booking for others and not attending the event

Main Group Contact

Contact Details (if not attending the event)

First Name

Last Name

Title

Position

Email Address

Verify Email Address

Contact Telephone Number

Primary Address

Line 1

Line 2

Town/City

County

Country

Postcode

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Group Members

Group Size

Please select the ticket type required below. This applies for the first person only, you will have the option to select the ticket types for other group members afterwards.

If you would like to utilise the 2-4-1 member discount please purchase two 2-4-1 member tickets first

Member 2-4-1 Tickets

All other tickets

Please select the days you would like to attend. To obtain the 2 for 1 discount on this ticket, please purchase 2 of these ticket types in a row and the total amount to pay will be adjusted accordingly.

Action Duchenne Member (2-4-1 offer)- 2 Day Conference Pass 11 & 12 November FULL

AMOUNT

0.00

TOTAL

Action Duchenne Member (2-4-1 offer)- 1 Day Conference Pass: 11 November FULL

AMOUNT

0.00

TOTAL

Action Duchenne Member (2-4-1 offer)- 1 Day Conference Pass: 12 November FULL

AMOUNT

0.00

TOTAL

Membership Number

Please select the days you would like to attend

2 Day Tickets (Friday & Saturday)

Action Duchenne Family Non-Member- 2 Day Conference Pass 11 & 12 November FULL

AMOUNT

0.00

TOTAL

Living with Duchenne- 2 Day Conference Pass 11 & 12 November FULL

AMOUNT

0.00

TOTAL

Please Note: This ticket is only available to those who have Duchenne. If you are a parent or carer, please book using the other tickets available.

PA/Professional Carer- 2 Day Conference Pass: 11 & 12 November FULL

AMOUNT

0.00

TOTAL

Child- 2 Day Pass 11 & 12 November FULL

AMOUNT

0.00

TOTAL

Friday Only Tickets

Action Duchenne Family Non-Member- 1 Day Conference Pass: 11 November FULL

AMOUNT

0.00

TOTAL

Living with Duchenne- 1 Day Conference Pass 11 November FULL

AMOUNT

0.00

TOTAL

Please Note: This ticket is only available to those who have Duchenne. If you are a parent or carer, please book using the other tickets available.

PA/Professional Carer- 1 Day Conference Pass 11 November FULL

AMOUNT

0.00

TOTAL

Child- 1 Day Pass 11 November FULL

AMOUNT

0.00

TOTAL

Saturday Only Tickets

Action Duchenne Family Non-Member- 1 Day Conference Pass: 12 November FULL

AMOUNT

0.00

TOTAL

Living with Duchenne- 1 Day Conference Pass 12 November FULL

AMOUNT

0.00

TOTAL

Please Note: This ticket is only available to those who have Duchenne. If you are a parent or carer, please book using the other tickets available.

PA/Professional Carer- 1 Day Conference Pass 12 November FULL

AMOUNT

0.00

TOTAL

Child- 1 Day Pass 12 November FULL

AMOUNT

0.00

TOTAL

Contact Details

First Name

Last Name

Title

Email Address

Verify Email Address

Contact Telephone Number

Primary Address

Address Line 1

Line 2

Town/City

County

Country

Postcode

Dietary Requirements

Other

Please note, your full name and dietary requirement if provided will be shared with the Jurys Inn Hinckley Island for the purpose of delivering this event.

Any special requirements?

Action Duchenne would like to offer families a £50 grant towards their conference accommodation to help towards the cost of attending the event. This grant is available due to the generosity of our sponsors for the event. Action Duchenne will be in touch with you after the event to arrange the reimbursement. There is one grant available per family.

Yes I would like to receive a £50 accommodation grant

No I do not require the grant

I agree to share my first and last name on the delegate list

Yes

If you would like to add dinner for Friday 11th November please select this below:

Adult (or children aged 13 or over) Dinner Ticket FULL

AMOUNT

30.00

TOTAL

Child (aged 12 or under) Dinner Ticket FULL

AMOUNT

8.50

TOTAL

If you would like to book the Creche please select the days required below (for children aged 0-9)

We have a limited number of creche spaces for children during the Conference.

Action Duchenne will confirm the availability of the creche placement with the Parent/Guardian ahead of the Conference.

Number Of

Friday FULL

Number Of

Saturday FULL

If you would like to book the Hangout please select the days required below (for children aged 10-17)

Number Of

Friday FULL

Number Of

Saturday FULL

Age of child

Parent/Guardian Name (on the day)

Parent/Guardian contact number (on the day)

Any special requirements?

Child Details

First Name

Last Name

Age of child

Dietary Requirements

Please note, your full name and dietary requirement if provided will be shared with the Jurys Inn Hinckley Island for the purpose of delivering this event.

Do you have any special requirements?

Parent/Guardian Name (on the day)

Parent/Guardian contact number (on the day)

Please click the days below you would like to book the Creche (for children aged 0-9)

We have a limited number of creche spaces for children during the Conference.

Action Duchenne will confirm the availability of the creche placement with the Parent/Guardian ahead of the Conference.

Number Of

Friday FULL

Number Of

Saturday FULL

Please select the days below you would like to book the Hangout (for children aged 10-17)

Number Of

Friday FULL

Number Of

Saturday FULL

Please select dinner below if you would like to add a child dinner for Friday 11th November

Child (aged 12 or under) Dinner Ticket FULL

AMOUNT

8.50

TOTAL

Child (aged 13-17) Dinner Ticket FULL

AMOUNT

30.00

TOTAL

Summary

Please note that if you are purchasing a 2 for 1 ticket type, ensure that you complete the registration form for 2 of these in a row and the total amount to pay will then be updated below. If you are having problems with your booking, please call 02476 369 747

Terms and Conditions

Agree

Payment

Thank you for Registering to attend the Action Duchenne International Conference. You will shortly receive a booking confirmation to your email. Should this not arrive please contact adconference@conferencecare.com or call +44 2476 369747  for assistance.

Don’t forget to book your accommodation if it is needed. The venue is offering hotel rooms at the special Action Duchenne rate. There are also alternative local hotel options. Please click here to view the accommodation options.

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Family/Individual Registration Form

Registration Form for Action Duchenne Members, Non-Members, Families, Children, Living with Duchenne and Carers

Contact Details (if not attending the event)

Primary Address

Group Members

Please select the ticket type required below. This applies for the first person only, you will have the option to select the ticket types for other group members afterwards.

If you would like to utilise the 2-4-1 member discount please purchase two 2-4-1 member tickets first

Please select the days you would like to attend. To obtain the 2 for 1 discount on this ticket, please purchase 2 of these ticket types in a row and the total amount to pay will be adjusted accordingly.

Please select the days you would like to attend

Contact Details

Primary Address

I agree to share my first and last name on the delegate list

If you would like to book the Creche please select the days required below (for children aged 0-9)

If you would like to book the Hangout please select the days required below (for children aged 10-17)

Child Details

Please click the days below you would like to book the Creche (for children aged 0-9)

Please select the days below you would like to book the Hangout (for children aged 10-17)

Summary

Terms and Conditions

Payment

Thank you for Registering to attend the Action Duchenne International Conference. You will shortly receive a booking confirmation to your email. Should this not arrive please contact adconference@conferencecare.com or call +44 2476 369747 for assistance.

Thank you for Registering to attend the Action Duchenne International Conference. You will shortly receive a booking confirmation to your email. Should this not arrive please contact adconference@conferencecare.com or call +44 2476 369747  for assistance.