COME LEARN, RENEW OLD FRIENDSHIPS, AND HAVE FUN AT
SBAA'S 30TH ANNUAL CONFERENCE (JUNE 23-25, 2003)
Hyatt Regency, San Antonio, TX
WWW.SBAA.ORG
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SAVE $ AND REGISTER NOW!
SBAA ANNUAL CONFERENCE REGISTRATION
DEADLINE EXTENDED TO FRIDAY, MAY 23
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SBAA has extended the deadline for "Regular"
conference registration fees until Friday,
May 23. Take advantage of this extension!

COME HEAR OUTSTANDING SPEAKERS & RELEVANT TOPICS
Psychosocial Issues, Urology, Orthopedics, Neurology, Sexuality,
Nonverbal Learning Disabilities and More!

MEET NEW FRIENDS
Young adults will want to join the ROUNDTABLE DISCUSSIONS.
Adults with Spina Bifida can talk freely about topics of interest
from Dating & Relationships, Self Advocacy & Disability Advocacy to
Employment.

HAVE FUN AT THE CONFERENCE SPECIAL EVENTS
*Opening Night Fiesta
Sunday, June 22, 2003, 6:30 – 8:00pm
Come meet the exhibitors
* Parents Night Out
Tuesday, June 24, 2003, 6:30 – 9:00 pm
Drop off the Kids. Enjoy a Reception. Then do whatever your heart
desires while the kids enjoy special babysitting/youth activities.

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ALREADY REGISTERED?
THANKS AND WE'LL SEE YOU IN SAN ANTONIO!
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REGISTER NOW!
For more information visit WWW.SBAA.ORG
*REGULAR REGISTRATION MUST BE POSTMARKED BY MAY 23*

For your convenience you can register three ways:
There are three easy ways to register

1. MAIL your registration to:
SBAA
4590 MacArthur Boulevard, NW, Suite 250
Washington, DC 20007-4226
MUST BE POSTMARKED BY MAY 23!!!

2. FAX your registration to:
202/944-3295

3. EMAIL your registration to:
registration@...
A form specially designed for email is in text below! Just fill in
and email it to us.

Download the Registration Form at
http://www.sbaa.org/docs/conf2003/conf2003_regform.pdf

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HERE'S THE REGISTRATION FORM IN EMAIL FORMAT:
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Spina Bifida Association of America
30th Annual Conference
June 22th–25th, 2003
San Antonio, TX

Please email to registration@...

A. REGISTRANT INFORMATION
Name
Program* Fee
Signature**

(Adult, Child, NHPC) (see chart below)

*If child please indicate specific children's program
number from page 2 section A.
**Signature indicates consent for SBAA to
photograph/videotape registrant for
promotional/educational purposes.

Number of wheelchairs used at conference
Adult
Child

Will you drive to conference?

Yes No

B. CONTACT NAME AND ADDRESS

Name:

Address:

City:
State: Zip:


Day phone:

Evening phone:

E-mail:

Member ID# (See Insights mailing label)

Please do not share my address with Exhibitors
Yes No

C. CELEBRATION LUNCHEON
(all adults welcome -M on. 12:00-2:30PM)

$20 per person x (qty) TOTAL $

D. PAYMENT INFORMATION

Registration Total $

Celebration Luncheon Total $

TOTAL PAYMENT ENCLOSED Total $

Paid by
Individual Chapter Institution


Name of organization

Please charge my
MasterCard Visa AmEx
Card# Exp. Date

Name (as it appears on card)

F. CANCELLATION/REFUND POLICY
Before May 23, 2003 - $25 fee
May 24 - June 20, 2003 - $50 fee
June 21, 2003 and later - no refund
All requests for refunds must be submitted in writing
marked "cancellation."

CONFERENCE FEES

All fees are per person.
Unless otherwise noted, all fees include attendance at
all four days of conference or the children's program.

Registration must be received at the National Office
by 6/16/03. All registrations received after that date
will be processed on-site.

REGISTRATION TYPE

Regular
postmarked 4/19-5/23 EXTENDED!
Late
postmarked 5/24-later

CONFERENCE ONLY (June 22 - 25)

Conference or Children's Program (SBAA member)
$265 $290
Each family member living at same address may each
attend at member price

Conference or Children's Program (nonmember)

$290 $315
(includes 1 yr family or individual membership-1st
registration at $290, additional at $265)

Conference or Children's Program (healthcare
professionals)
$305 $330
(nonmember, includes 1 yr professional/agency/school
membership)

One-Day Program (Spanish session or any one day
attendance)
$100 $100

CONFERENCE & NHPC EDUCATION DAY

Nursing & Healthcare Professionals Council (NHPC)
(SBAA member)
$345 $370

NHPC (nonmember, includes one year SBAA professional
membership)
$385 $410

NHPC EDUCATION DAY ONLY (June 22)

NHPC Education Day (SBAA member)

$145 $170

NHPC Education Day (nonmember, includes 1 yr prof. membership)

$185 $210


If you are enrolling more than one child please make
photocopies of this form prior to completion.
A separate form is required for each child. Please
attach an additional sheet for expanded explanations.

2003 Children's Registration Form Child #__ of __

Please answer each question completely. If the
question does not apply your child, indicate N/A in
the space provided. As in the past, all Children's
Programs will have a maximum capacity in order to
ensure quality programming.

A. BACKGROUND INFORMATION

Which program are you enrolling your child in?
__ 1 Infant/Toddler (0-3 years) with or without
spina bifida

__ 2 Preschool (4-6 years) with or without spina
bifida

__ 3 Youth (7-12 years) with or without spina bifida

__ 4 Teen (13-19 years) with spina bifida only

__ Brother & Sister (13-19 years) without spina
bifida only

Participant's Name

Sex: Birthdate:
Age:

B. DOES YOUR CHILD HAVE SPINA BIFIDA?

Yes No
(If yes, please complete the
entire form. If no, please skip to section C)

Diagnosis in addition to spina bifida:

Level of lesion: Part of body affected:


School Grade in Fall 2003:

Is your child verbal? No Yes

Does your child have ADD? No Yes

If so, please explain behaviors that staff should be
aware of

Does your child have a feeding problem?
No Yes

If yes, please explain


Does your child have seizures?
No Yes

If yes, please explain type, frequency, etc.

Primary Mobility?
Manual Wheelchair
Electric Wheelchair
Walks Unassisted

Walks with Assistive Devices

Please give details

Can your child transfer from chair?
No Yes

Does he/she need help or assistance?
No Yes

C. MEDICAL INFORMATION

Does your child have allergies?
No Yes

Please list:

Medications: (For informational purposes only. All
medications must be administered by parent/guardian).

Name
Dosage Time

Name
Dosage Time

Name
Dosage Time


D. BOWEL/BLADDER INFORMATION (Infant/toddler and
preschool program only. Youth cathed by age group once
in am and pm)

Child:
__Is in diapers
__Toilet trained
__Cathed

Catheterization Schedule (9:00 am-4:30 pm)

Time ________ Cathed by Nurse / Parent / Child Assists

Time ________ Cathed by Nurse / Parent /Child Assists

Has your child had bladder augmentation surgery?
No Yes

Does your child cath through the urethra?
No Yes

If no, please explain

Please describe any specific routines you use with
your child regarding either diaper changing or
catheterization:


E. NAPPING & FEEDING INFORMATION
Nap Time Length
Feeding Time Food

Nap Time Length
Feeding Time Food

F. CONSENT AND RELEASE
To be read and signed by parent/guardian. Parent with
primary custody must sign.
My child may be picked up from the Children's Program
only by the following individuals:
_______________________________________
_______________________________________
_______________________________________

1. I hereby consent for my child to attend and
participate in the SBAA Annual Conference Children's
Program; and

2. I hereby consent for my child to be
photographed/vidoetaped while attending the Children's
Program and for such photographs/videos to be used for
promotional and educational purposes; and

3. I hereby consent for a licensed RN, LPN or
qualified Nurse's Aide to meet my childs
catheterization needs. I will provide supplies needed
for catheterization. I also consent to allow the
nursing staff and other program staff to contact the
community medical emergency services in the case of an
emergency and when immediate medical care is necessary
for my child in my absence. I will be solely
responsible for the costs incurred if an emergency
exists; and

4. I hereby, for myself, my child, my heirs,
administrators, personal representatives, executors
and assignees, release and discharge the Spina Bifida
Association of America, its employees, agents,
volunteers and contractors, and the Hyatt Regency, San
Antonio, property and management from any and all
damages or causes of action, either at law or equity,
which I may have or acquire or which may accrue to me,
my child, my heirs, administrators, personal
representatives, executors and assignees as result of
participation in the Children's Program including
provision of any medical services being provided at
the 2003 SBAA Annual Conference.

Parent/Guardian:

Date:

Please Note:
1) If you medicate/cath your child during the program,
you must check in with the nursing staff before you
enter/exit designated areas.
2) A written doctor's order is required for any
catheterization procedure performed on-site by nurses
during the children's program. The doctor's order must
be sent with registration or provided on-site.

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Conference Registration Deadlines - SAVE $ AND REGISTER NOW!

REGULAR: POSTMARKED NO LATER THAN 5/23
Late: postmarked 5/24- later

For more information, please visit WWW.SBAA.ORG
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