REGISTER NOW! LIVING BETTER TOGETHER. COPD Conference. ìì NOVEMBER 16, COPD Conference

Transcription

1 LIVING BETTER TOGETHER COPD Conference REGISTER NOW! Registration forms enclosed OR register online at ìì NOVEMBER 16, W Washington Blvd Chicago, IL Non Profit Org. U.S. Postage PAID Chicago, IL Permit No TH ANNUAL ìì THURSDAY, NOVEMBER 16, 2017 LIVING BETTER TOGETHER COPD Conference A conference for people living with COPD, their families and caregivers PRESENTING SPONSOR LEAD SPONSOR OXYGEN PROVIDER U U

2 2017 LIVING BETTER TOGETHER COPD CONFERENCE THURSDAY, NOVEMBER 16, :30 a.m. Registration and continental breakfast available 10:00 a.m. Conference begins 3:00 p.m. Conference concludes MERIDIAN BANQUETS & CONFERENCE CENTER 1701 Algonquin Road, Rolling Meadows, Illinois, $30 REGISTRATION FEE INCLUDES: > Morning refreshments > Keynote panel > Educational sessions > Exhibit access > Luncheon > On-site supplemental oxygen (for those prescribed only) > Bus transportation from select sites Buses are provided for groups of 15+ registrants traveling from the same site. These will be arranged after registration has closed. Confirmation letters with transportation information will be mailed by November 3. KEYNOTE PANEL COPD Flare-ups: What to Do. An expert panel discussion on flare-up prevention and management EDUCATION SESSION DESCRIPTIONS Registration includes choice of morning session and afternoon session. Please mark a selection from each column below on registration form. MORNING SESSIONS SESSION 1. Understanding Medication Coverage Learn more about navigating COPD medication coverage SESSION 2. I Can't Cough it Up: Airway Clearance Therapy Learn more about proper bronchial hygiene and available devices to assist with airway clearance SESSION 3. Patient Empowerment: Advance Care and Future Planning Learn more about building a care team when managing COPD AFTERNOON SESSIONS SESSION 4. What's Next: Treatment Options in COPD Learn more about COPD treatment options beyond pharmacological, oxygen and rehabilitation therapy SESSION 5. Mindfulness-Centering and COPD Learn how mindfulness practice may lead to improved COPD management and wellness SESSION 6. Understanding Medication Coverage Learn more about navigating COPD medication coverage (repeat of morning session) Contact Jennifer at (312) or jkustwin@lungchicago.org with questions Register online at Out of courtesy to people living with COPD, please refrain from wearing cologne or perfume to the event; it can exacerbate breathing difficulties. Thank you, and we look forward to seeing you at the conference!

3 2017 LIVING BETTER TOGETHER COPD CONFERENCE - REGISTRATION FORM PARTICIPANT INFORMATION (Each registrant must complete both sides of this form) I am: Living with COPD Family/Friend of: Pulm Rehab Staff Other Last Name: First Name: Street Address: City, State and ZIP Code: Home Phone: Cell Phone: (ex: johndoe@ .com): Name of your hospital or pulmonary rehab group: If you have attended this event in the past, please indicate which year(s): Select a Meal Preference: Non-vegetarian Vegetarian I would be interested in contacting legislators to improve lung health policy: Yes No If yes, I would like to: Write Letters Make Phone Calls Send s Meet with local officials BUS TRANSPORTATION (Provided to groups of 15+ registrants from same site; arranged after registration closes) If possible, I would like to travel by bus with a group: Yes No If yes, I would prefer to travel: With my hospital/pulm rehab group From the site closest to my home Other (list group name): SUPPLEMENTAL OXYGEN Will you need supplemental oxygen at the conference? Yes No If yes, please specify: Oxygen liters per minute (LPM) Do you have any special needs? EDUCATIONAL SESSIONS (Review the session descriptions on the previous page before making your selections) Registration includes choice of Morning Session and Afternoon Session. Please mark a selection in each column below. MORNING SESSION CHOICE AFTERNOON SESSION CHOICE 1. Understanding Medication Coverage 4. What's Next: Treatment Options in COPD 2. I Can't Cough It Up: Airway Clearance Therapy 3. Patient Empowerment: Advance Care and Future Planning 5. Mindfulness-Centering and COPD 6. Understanding Medication Coverage (repeat of morning session) Page 1 of 2

4 2017 LIVING BETTER TOGETHER COPD CONFERENCE THURSDAY, NOVEMBER 16, 2017 REGISTRATION CLOSES OCTOBER 27, 2017 OR WHEN ALL SPACES ARE FILLED Each registrant must complete both sides of this form OR register online at RELEASE OF LIABILITY Please read and complete the waiver below. Your signature is required for your participation in the event. I understand that Living Better Together COPD Conference is a one-day event that may include transportation in buses hired by Respiratory Health Association (RHA) to and from Meridian Banquets & Conference Center on November 16, I hereby waive any and all claims against RHA and each of its agents, employees, and volunteers. I understand that I will be responsible for any personal belongings and equipment that I bring with me to the conference and RHA is not responsible for their loss, misuse, or abuse. I understand medical support is not available during this event and represent that I am in sufficiently good medical condition to participate in the conference. In the event of a medical emergency, I authorize RHA to obtain any medical transportation and appropriate medical care needed. PARTICIPANT SIGNATURE DATE EMERGENCY CONTACT (PLEASE PRINT NAME) RELATIONSHIP TO PARTICIPANT EMERGENCY CONTACT PHONE NUMBER NOTE ABOUT PHOTOGRAPHY Respiratory Health Association takes photos and videos at this event to share with you and your pulmonary rehab group and to promote Living Better Together COPD Conference in Inspiration COPD Newsletter, online and in local newspapers. We do not use the names of people photographed without their expressed permission. I do NOT want my picture taken at this event. REGISTRATION FEE: $30 **THIS FEE IS NON-REFUNDABLE** I will pay by: Cash Check Please make checks payable to Respiratory Health Association Credit/Debit Card Visa MasterCard AmEx Discover Credit Card Number: Exp. Date: CVV Code: Name as it appears on card: Billing Zip Code: Although Respiratory Health Association offers event registration for $30, Living Better Together COPD Conference's actual cost is $90 per person. You can make a tax-deductible donation to help defray expenses, enable us to expand our educational outreach, and support for people living with lung disease. Thank you for your consideration. Registration fee ($30 per person): Donation amount (optional): Total enclosed: BEFORE YOU SEND, PLEASE BE SURE TO: Select a Meal Preference (pg 1) Indicate Supplemental Oxygen/Special Needs (pg 1) Choose ONE Morning/ONE Afternoon Session (pg 1) Sign the Release of Liability (pg 2, above) CONTINUING EDUCATION FOR RCPs Respiratory Care Practitioners (RCPs) have been approved for 2.5 hours of continuing education credit. Provide your license number below to receive CEUs. RCP License (if applicable): MAIL REGISTRATION FORM & PAYMENT TO: Respiratory Health Association ATTN: COPD Initiative 1440 W Washington Blvd Chicago, IL Contact Jennifer at (312) or jkustwin@lungchicago.org with questions Page 2 of 2

5 2017 LIVING BETTER TOGETHER COPD CONFERENCE - REGISTRATION FORM PARTICIPANT INFORMATION (Each registrant must complete both sides of this form) I am: Living with COPD Family/Friend of: Pulm Rehab Staff Other Last Name: First Name: Street Address: City, State and ZIP Code: Home Phone: Cell Phone: (ex: johndoe@ .com): Name of your hospital or pulmonary rehab group: If you have attended this event in the past, please indicate which year(s): Select a Meal Preference: Non-vegetarian Vegetarian I would be interested in contacting legislators to improve lung health policy: Yes No If yes, I would like to: Write Letters Make Phone Calls Send s Meet with local officials BUS TRANSPORTATION (Provided to groups of 15+ registrants from same site; arranged after registration closes) If possible, I would like to travel by bus with a group: Yes No If yes, I would prefer to travel: With my hospital/pulm rehab group From the site closest to my home Other (list group name): SUPPLEMENTAL OXYGEN Will you need supplemental oxygen at the conference? Yes No If yes, please specify: Oxygen liters per minute (LPM) Do you have any special needs? EDUCATIONAL SESSIONS (Review the session descriptions on the previous page before making your selections) Registration includes choice of Morning Session and Afternoon Session. Please mark a selection in each column below. MORNING SESSION CHOICE AFTERNOON SESSION CHOICE 1. Understanding Medication Coverage 4. What's Next: Treatment Options in COPD 2. I Can't Cough It Up: Airway Clearance Therapy 3. Patient Empowerment: Advance Care and Future Planning 5. Mindfulness-Centering and COPD 6. Understanding Medication Coverage (repeat of morning session) Page 1 of 2

6 2017 LIVING BETTER TOGETHER COPD CONFERENCE THURSDAY, NOVEMBER 16, 2017 REGISTRATION CLOSES OCTOBER 27, 2017 OR WHEN ALL SPACES ARE FILLED Each registrant must complete both sides of this form OR register online at RELEASE OF LIABILITY Please read and complete the waiver below. Your signature is required for your participation in the event. I understand that Living Better Together COPD Conference is a one-day event that may include transportation in buses hired by Respiratory Health Association (RHA) to and from Meridian Banquets & Conference Center on November 16, I hereby waive any and all claims against RHA and each of its agents, employees, and volunteers. I understand that I will be responsible for any personal belongings and equipment that I bring with me to the conference and RHA is not responsible for their loss, misuse, or abuse. I understand medical support is not available during this event and represent that I am in sufficiently good medical condition to participate in the conference. In the event of a medical emergency, I authorize RHA to obtain any medical transportation and appropriate medical care needed. PARTICIPANT SIGNATURE DATE EMERGENCY CONTACT (PLEASE PRINT NAME) RELATIONSHIP TO PARTICIPANT EMERGENCY CONTACT PHONE NUMBER NOTE ABOUT PHOTOGRAPHY Respiratory Health Association takes photos and videos at this event to share with you and your pulmonary rehab group and to promote Living Better Together COPD Conference in Inspiration COPD Newsletter, online and in local newspapers. We do not use the names of people photographed without their expressed permission. I do NOT want my picture taken at this event. REGISTRATION FEE: $30 **THIS FEE IS NON-REFUNDABLE** I will pay by: Cash Check Please make checks payable to Respiratory Health Association Credit/Debit Card Visa MasterCard AmEx Discover Credit Card Number: Exp. Date: CVV Code: Name as it appears on card: Billing Zip Code: Although Respiratory Health Association offers event registration for $30, Living Better Together COPD Conference's actual cost is $90 per person. You can make a tax-deductible donation to help defray expenses, enable us to expand our educational outreach, and support for people living with lung disease. Thank you for your consideration. Registration fee ($30 per person): Donation amount (optional): Total enclosed: BEFORE YOU SEND, PLEASE BE SURE TO: Select a Meal Preference (pg 1) Indicate Supplemental Oxygen/Special Needs (pg 1) Choose ONE Morning/ONE Afternoon Session (pg 1) Sign the Release of Liability (pg 2, above) CONTINUING EDUCATION FOR RCPs Respiratory Care Practitioners (RCPs) have been approved for 2.5 hours of continuing education credit. Provide your license number below to receive CEUs. RCP License (if applicable): MAIL REGISTRATION FORM & PAYMENT TO: Respiratory Health Association ATTN: COPD Initiative 1440 W Washington Blvd Chicago, IL Contact Jennifer at (312) or jkustwin@lungchicago.org with questions Page 2 of 2