IPCC 2022 Hybrid Symposium Registration

18th Annual International Pachyonychia Congenita Consortium (IPCC) Symposium
May 18, 2022
8am - 12:30pm PDT
to be a hybrid meeting - attend in person in conjunction with the Society of Investigative Dermatology (SID) Annual Meeting in Portland, Oregon or virtually via zoom.

1. Contact Information

First Name
Last Name
Title/Credentials
Affiliation/Institution
Email Address

Please enter the best mailing address for you.

2. How do you plan to attend the meeting?

Please list dietary requirements, if any.

Would you like to join PC Project and other IPCC Symposium members at a hosted dinner on Tuesday, May 17th?

3. Do you have information you would like to present regarding PC-related research? (Our program is mostly full at this time, but we can evaluate your material for future meetings.)

Please enter an 'other' value for this selection.

4. Please list any topics or questions you would like discussed at the IPCC Symposium.

5. We invite anyone to join who is interested in PC and other PPKs to join us. Is there anyone you think PC Project should invite who might be interested in our disease space? Please list name(s), and if possible, contact information here.

6. In a few words, please describe your interest in Pachyonychia Congenita or other related diseases.

7. Photo & Video Consent Form
- I hereby give my consent to have photographs and/or video taken of myself during the meeting which will be used by PC Project or PC Project Europe for educational, promotional and research purposes.
- I understand that these photograph(s) and/or video may appear in the public media, including print, internet and/or broadcast media for an indefinite period of time.
- I have been informed that these photograph(s) and/or video may be used more than once for educational and promotional purposes by PC Project.
- I understand I have the right to withdraw the photograph(s) and/or video by a written request to PC Project.

Type Name as Signature
Date