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The MAGIC Foundation's 29th Annual Convention Registration Form
First Name
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Last Name
*
Street Address
*
Address Line 2
City
*
State
*
NOT APPLICABLE / NOT IN USA
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Province (if Canada)
Country
*
Zip or Postal Code
*
Phone Number
*
Email Address
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List any additional ADULTS attending the convention, include last names if different.
List the name of your affected child #1 attending
Affected Child's Age
Affected Child's Sex
Male
Female
List the name of your affected child #2 attending
Affected Child's Age
Affected Child's Sex
Male
Female
Affected Child's Disorder(s). Please check your child's primary disorder:
CAH
GHD
MAS/FD
ONH
PAN
RSS
SGA
Temple
Other
Endocrinologist Name
Endocrinologist City
Name of additional child attending
Age of additional child
Sex
Male
Female
Name of additional child attending
Age of additional child
Sex
Male
Female
Name of additional child attending
Age of additional child
Sex
Male
Female
Name of additional child attending
Age of additional child
Sex
Male
Female
Name of additional child attending
Age of additional child
Sex
Male
Female
Name of additional child attending
Age of additional child
Sex
Male
Female
THURSDAY
The registration fee of $125 includes immediate family only and also includes a one-year membership to MAGIC. Please choose the correct option below:
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Congenital Adrenal Hyperplasia
Growth Hormone Deficiency
McCune Albright Syndrome/Fibrous Dysplasia
Optic Nerve Hypoplasia/Septo Optic Dysplasia
Panhypopituitarism
Russell Silver Syndrome
Small for Gestational Age
Temple Syndrome
Non-affected/No disorder
Additional adults are $25 each and may include grandparents, aunts/uncles or friends. Please check the number of any additional adults attending the convention.
1 Additional Adult ($25)
2 Additional Adults ($50)
3 Additional Adults ($75)
4 Additional Adults ($100)
5 Additional Adults ($125)
Dental Screening
Would you like a complimentary dental screening with Dr. Kirt Simmons?
*
Yes
No
If you are requesting a dental screening, please list a time frame that works for you. Appointments are between the hours of 2:00 pm - 6:00 pm. Please remember to be on time for these screenings since they are only 15 minutes.
FRIDAY
Childcare Program/Kid's Camp
Childcare Program/Kid's Camp - Price is $50 per child per day. Enter the number of kids for each day.
Friday Childcare/Kid's Camp
Saturday Childcare/Kid's Camp
Please list full names of those attending childcare/camp
Field Trip to the Museum of Science and Industry
Please check which best describes kids going on the field trip
My child(ren) need a chaperone
No chaperone needed - attending with a family member or friend
Friday field trip to the Museum of Science and Industry (6 years and older unless accompanied by a family member). Price is $40 per person which includes admission, transportation and a boxed lunch. Please enter the total number of people attending, including any adults that may be chaperoning their own children.
1 Field Trip ($40)
2 Field Trip ($80)
3 Field Trip ($120)
4 Field Trip ($160)
5 Field Trip ($200)
6 Field Trip ($240)
Please list the name and age of CHILDREN attending trip
Please list the name and age of ADULTS attending trip
If you have a friend or chaperone you wish to be grouped with, please list their name here:
Pajama Jammin' Party
Buffet Dinner is included in the price: $18 (ages 12+), $12 (ages 3-11), 2 and under are free!
Friday - Ages 12+ ($18)
Friday - Ages 3-11 ($12)
Friday - Ages 2 and Under (Free)
Do you have any dietary needs/restrictions? If so, please list (and be specific).
Friday Educational Segments
Enter the number of people attending each of the educational segments in the space next to each division.
CAH
GHD
MAS/FD
ONH
PAN
RSS/SGA/TEMPLE
SATURDAY
Saturday General Segments (All divisions)
Enter the total number of people attending each general session in the box below it.
Emotional and Mental Health for Pituitary Patients and their Families
When Should I Be Concerned about Puberty and What are My Treatment Options?
Learn More about the Pharmaceutical Patient Support Programs
Marvelous Magical Carnival
Buffet Dinner is included in the price: $18 (ages 12+), $12 (ages 3-11), 2 and under are free!
Saturday - Ages 12+ ($18)
Saturday - Ages 3-11 ($12)
Saturday - Ages 2 and Under (Free)
Do you have any dietary needs/restrictions? If so, please list (and be specific).
Is it after June 20, 2023? If yes, a late fee of $25 will be added.
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Yes
No
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