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January 2022 Latam SRF Meeting in San Diego
Please fill out this form by DECEMBER 15 if you are planning on speaking or attending the meeting in San Diego, California on January 21-23.
Agradecemos completar el formulario a continuación antes del 15 DE DICIEMBRE si planea asistir a la reunión en San Diego, California, del 21 al 23 de enero.
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Email
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Your email
Are you a speaker or a SYNGAP family? ¿Eres un conferencista o una familia SYNGAP?
Speaker
Family
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Name, Address, Email, and Phone of person registering: Nombre, Dirección, Email, Teléfono de la persona que realiza el registro;
Your answer
WHO IS COMING - QUIENES VIENEN
Name of parent - Nombre del Padre
Your answer
Name of Syngapian - Nombre del paciente con Syngap
Your answer
Name(s) of other family members coming - Nombre de las otras personas que asistirán
Your answer
LODGING - HOSPEDAJE
We will book a room with two queen beds. Please let us know if this is okay or if you require an accessible room or other accommodations. - Reservaremos una habitación con dos camas tamaño queen. Háganos saber si esto está bien o si necesita una habitación accesible u otras adaptaciones para su familia.
Your answer
SCHOLARSHIP APPLICATION - APLICACION PARA EL SUBSIDIO
We will support some travel. Please answer the following questions:
Vamos a apoyar los costos de viaje. Por favor contestar las siguientes preguntas:
Do you require support? Requiere subsidio de viaje?
Yes
No
Maybe
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How much funding are you requesting? Cuanto subsidio requiere?
Your answer
Brief description of how you plan to use these funds: Por favor enviar una pequeña descripción de como planea usar los fondos:
Your answer
Thank you! We will confirm your approved amount within 72 hours. We prefer to reimburse against receipts, but if you need us to make bookings please let us know. ¡Gracias! Confirmaremos su cantidad aprobada dentro de las 72 horas. Preferimos reembolsar con recibos y comprobantes de pago, pero si necesita que hagamos reservas, favor comunicarlo.
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