Online Registration form for the 2012 Convention

2012 - The 7th Annual Educational convention for Adults with Pituitary Discorders  

Includes: Adult Growth Hormone Deficiency, Panhypopituitarism, Cushings and Acromegaly
July 19-22, 2012
Westin- Lombard
Chicago, Illinois
UNDER CONSTRUCTION (The program book is being developed and will be available online soon. For immediate information please email or call our office: ContactUs@magicfoundation.org or (708) 383-0808.)

You may choose to secure your registration by using the online registration form below. REMEMBER- this page has security settings on it. It will time out without you ever knowing it and FAIL to go through with an error. Therefore, to ensure that this goes well for you do this:

1. Have your decision about who is going etc. already in mind.
2. Have your credit card handy.
3. Hit refresh on your page (the up and down green arrows at the top of your browser) so that the time starts then. Once you refresh your page, the security system will allow for 7 minutes to complete the form before a problem occurs. If you need help, you can call the office and register via the phone. Mon-Fri,  9-4 Central Time / call (708) 383-0808.

2012 Adult Convention Online Registration

Name of Affected Adult
Name of other adults attending
Mailing address
City
State
Zip Code
Daytime phone number (please include your area code)
Email address in case of registration problems
Your medical disorder/diagnosis
Your Endocrinologist
What city does the Endo practice in?
Registration costs are all inclusive: $180 for a MAGIC member, or $210 for a non-member. This applies to the first person only.
Additional adults attending are $95.00 each
How many adults are attending?
Are you attending the Luau Dinner Party
How many people will be attending the Luau?
Are you a current paid member of MAGIC?	yes no
Payment Options	MasterCard Visa Discover
Will you be attending the Welcome Reception on Friday?	yes no
Credit Card Number
Name exactly as it appears on your card
Expiration Date
List the exact amount you are authorizing The MAGIC Foundation to bill to your CC for your Registration
List the CC billing address if it is different from the address you listed above.
Please Enter Code Into the Textbox Below (CODE IS CASE-SENSITIVE):