2023 Mini Camp Wonder Form

2023 Mini Camp Wonder at PeDRA Registration Form

Mini Camp Wonder at the PeDRA Conference is being held on Friday, November 10, 2023, from 3:30 - 5:30 PM at the Westin Buckhead Atlanta Hotel. Registration for Mini Camp Wonder at the PeDRA Conference must be completed by a parent or adult caregiver of the camp participant no later than Saturday, October 14, 2023. A separate form must be completed for each child that wishes to participate.

2023 PeDRA Annual Conference Travel Scholarships

PeDRA is proud to offer Travel Scholarships to help offset the cost of travel for PeDRA Trainee Members, PeDRA Community Members or PeDRA Community Members applying for support on behalf of a child under 18, and Active or Affiliate Members within two years of completing training. Scholarships are available to eligible applicants from all backgrounds including, but not limited to, individuals from communities that are underrepresented in medicine (URiM). Scholarships will be awarded following an application and competitive review process, depending on the availability of funds and the merit of applications received. To be considered, submit an application before 5 PM PT on October 14, 2023.

**Family members are defined as a parent or a guardian of a Mini Camp Wonder camper and the Mini Camp Wonder camper. More than one family member is eligible to receive a travel scholarship. Each family member who wishes to receive a travel scholarship must submit a separate application to be considered for the travel scholarship.

Permission to participate

By checking the box, I hereby grant permission for my child to participate in Camp Wonder at PeDRA.

Acknowledgement of age

By checking the box, I hereby acknowledge that the Camp Wonder at PeDRA registered participant is over the age of 6 and under the age of 18. Children that will be 5 years old on November 9, 2023, may still be eligible to participate if they are potty-trained.

Camper's First Name

Camper's Last Name

Only last initials will be used on the badges.

Camper's age on November 9, 2023

If they have one, please provide the camper's nickname:

Please indicate below the camper's desired pronouns to be listed on their name badge.

Please provide the camper's parent or guardian's name, email address, and emergency contact phone number.

First Name

Last Name

Parent or Guardian's Email

Please provide their parent's or guardian's emergency contact phone number.

If applicable, please provide the name of the organization or patient community with which you are involved:

Will the parent or guardian also be joining us in person for the 2023 PeDRA Annual Conference?

YesNoIf yes, please register for the 2023 PeDRA Annual Conference here .

Current Street Address

City

Country

State

State/Province

Province

Postal Code

What type of address is this?

PersonalBusinessOther

Photography and Videography

PeDRA may capture photographs and video during the 2023 Annual Conference. By this release, I consent to the recording, videotaping, or photographing of my image and/or voice by Pediatric Dermatology Research Alliance Inc. (PeDRA”), perpetually and throughout the world, (a) in connection with any video, audio, or photographs taken in connection with the PeDRA Annual Conference, (b) in any related advertising, video or audio recordings, printed publications and Internet publications, and (c) in any other medium for a related purpose. I also consent to the use of my name in such media. I acknowledge and agree that PeDRA, and its successors and assigns, is the sole owner of all copyrights, literary rights, and similar rights to such media. PeDRA agrees to preserve the integrity of my likeness, voice, and name. By this release, I consent to the use of my likeness in such photograph(s) perpetually and for all media worldwide (including print, Internet, and any other electronic medium). I understand and agree that I shall receive no compensation for the use of my likeness, voice, and name in such media.

I am over eighteen (18) years of age. If I am also registering on behalf of someone under eighteen (18) years of age, I represent that I am the parent or guardian of such person. I hereby consent to the foregoing on his/her behalf.

I Agree

I do not agree, however, I acknowledge having read this Photography and Videography Release and that my likeliness and voice, or that of someone under the age of eighteen (18) for whom I am registering, may appear in photos or videos of group settings or public areas that are used by PeDRA for advertising, video or audio recordings, printed publications, internet publications, or in any other medium for a related purpose, perpetually and for all media throughout the world.

PeDRA is committed to supporting equity, diversity, and inclusion across all facets of its organization, programs, committees, leadership, and research studies. We ask for demographic information from PeDRA Annual Conference attendees to ensure we have accurate and complete data to help achieve this goal. All data collected is kept safely and only de-identified aggregate data will be shared strategically.

Please specify the camp participant's gender:

FemaleMaleNon-binaryI do not wish to provide this information.

With what race(s) does the camp participant self-identify? Please select all that apply.

Other - write in race:

Accessibility and Special Needs

Pursuant to the Americans with Disability Act (ADA), do you have any special needs or requirements?

Please indicate any special dietary needs:

Other special dietary needs:

Acknowledgment of Personal Responsibility for 2023 Mini Camp Wonder at PeDRA Annual Conference Campers

PeDRA is committed to providing a safe and healthy environment for all conference attendees, exhibitors, partners, and the administrative team.

I acknowledge that PeDRA cannot guarantee that I will not be exposed to or contract a Communicable Disease (e.g. COVID-19) at the 2023 Mini Camp Wonder at PeDRA Annual Conference and I understand the risk that myself and my child may be exposed to or infected by a Communicable Disease by attending. I knowingly and freely assume all such risks, both known and unknown, and take full personal responsibility for my child's and my participation in the conference. PeDRA asks that all attendees respect each other's preferences for masking and social distancing.

I agree to abide by all applicable COVID-19-related requirements, advisories, policies, procedures, and protocols of the event hosts (PeDRA), the Westin Buckhead Atlanta, as well as respective PeDRA partners, and any other governmental authority for the duration of the event.

With my response below, I release PeDRA, its Meetings Committee, the Board of Directors, staff, and contractors from liability should my child or I become ill, directly or indirectly, as a result of my participation in this event.

I acknowledge personal responsibility for myself and my child.

In addition to conference updates, do you wish to receive regular updates from PeDRA via email?

Yes

Any additional information you'd like to provide about your child or children:

Contact Information

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2023 Mini Camp Wonder at PeDRA Registration Form

Accessibility and Special Needs

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