IPCC 2021 Virtual Meeting Registration

17th Annual International Pachyonychia Congenita Consortium (IPCC) Symposium
June 28-29, 2021
8am - 11am MDT Both Days
to be held virtually

1. Contact Information

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

Please enter the best mailing address for you.

2. The program is finalized for this meeting. However, do you have information you would like to present to our collaborators regarding PC-related research at a future meeting?

Please enter an 'other' value for this selection.

3. Please list any topics, questions or collaborations you would like to be discussed or made.

4. Is there anyone you think PC Project should invite? Please list name(s), and if possible, contact information here.

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

6. 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 my name and personal identifying information will not be associated with the photograph(s) and/or video without my additional written consent.
- 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