2023 Conference Registration Form

2023 PeDRA Annual Conference Registration Form

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Please complete the following form to register for the 2023 PeDRA Annual Conference. We look forward to seeing you in Atlanta!

Send an email to conference@pedraresearch.org or call 971-369-0386 if you have questions along the way or encounter any trouble with the form.

Note that you may save your progress through the form and return later by clicking "Save my progress and resume later" at either the top or bottom of this form.

2023 PeDRA Annual Conference Travel Scholarships

PeDRA is proud to offer Travel Scholarships to help offset the cost of travel for Trainee Members, Community Members, 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 September 14, 2023.

If you are interested in a scholarship but not a PeDRA member, you can apply to become a member here. You may register under your anticipated category while your membership application is being reviewed.

Trainee Members, who are medical students, must also be accepted to participate in the NextGen Research Forum with a short presentation to be eligible to receive a Travel Scholarship. This stipulation does not apply to any other member category.

Registration Details

Please select your registration category:

Note: these are early-bird prices available until Thursday, July 20, 2023. Prices will increase at 12:00 AM PT on Friday, July 21. The deadline to register for the 2023 PeDRA Annual Conference is Thursday, October 26.

Note to industry partners – industry participation at the 2023 PeDRA Annual Conference will be limited to representatives from the PeDRA Corporate Council or companies supporting the conference. Eligible companies will be provided with a code for representatives to register using the non-member category. Please email mike.siegel@pedraresearch.org with any questions about industry registration, the PeDRA Corporate Council, or conference support opportunities.

Attendee Information

Please provide your name exactly how you would like it to be printed on your conference badge and listed on the conference app. Please be aware it will be printed or listed exactly as you enter it and will not be edited.

First Name

Last Name

Please provide any credentials you would like listed on your conference badge:

Please indicate your desired pronouns to be listed on your conference badge.

Other - please describe

Primary Affiliation

This will appear on your conference badge exactly as you enter it. Please write out the full institution or organization name instead of using acronyms or abbreviations.

Email Address

Note: This email will be used to grant you access to the PeDRA Conference App. If you are a PeDRA member, please provide the email address associated with your PeDRA membership profile.

Which stakeholder group best describes what group you are a part of?

Government AgencyIndustry Partner (please note, registration for industry partners is only open to companies supporting the PeDRA 2023 PeDRA Annual Conference. If you have questions, please email mike.siegel@pedraresearch.org)A Medical professional is either involved in or interested in dermatology and you're not eligible for another stakeholder group. Trainees and Advocacy partners should register in a different category.

Please select what most accurately describes your current position:

Senior Clinician and/or InvestigatorMid-Career Clinician and/or Investigator (between 7 and 15 years out of training)Early Career Clinician and/or Investigator (between 2 and 7 years out of training)New Clinician and/or Investigator (within 2 years of finishing training)Clinical FellowResidentResearch FellowMedical or Graduate StudentOther

Other - please describe

Please tell us more about yourself. Select all that apply:

I am the parent or guardian of a pediatric patient. I am a representative from a patient advocacy organization.I am a patient (over the age of 18).

Position

Senior Organizational Leadership (CEO or similar)Scientific and/or Medical Leadership (CSO/CMO, Medical Director, or similar)Advocacy or Professional Relations LeadershipScientific and/or Medical Affairs StaffAdvocacy or Professional Relations StaffOther

Please provide your position description here:

Have you attended a PeDRA Annual Conference in the past?

Yes, I have attended both in-person and virtual PeDRA Annual Conferences in the pastYes, I have attended in-person PeDRA Annual Conference(s) onlyYes, I have attended virtual PeDRA Annual Conference(s) onlyNo, 2023 will be my first PeDRA Annual Conference

Industry Representative Attestation

As is the case for all attendees at the PeDRA Annual Conference, industry representatives are expected to respect the open, collaborative environment that PeDRA is committed to providing at its conference, and to prioritize the advancement of PeDRA's mission and vision during their time as a conference attendee. Industry representatives are free and encouraged to engage in activities throughout the main conference agenda including plenary sessions, innovation workshops, networking events, poster sessions, and exhibits, and are encouraged to make connections with other attendees at the conference through in-person interaction and the conference app. Industry representatives are further encouraged to review the 2023 PeDRA Annual Conference Prospectus for a full list of company partnership opportunities to get the most value out of their experience.

In addition to the activities listed above, the PeDRA Annual Conference includes a series of breakout sessions intended as venues for PeDRA investigators, trainees, and patient partners to discuss new and ongoing collaborative studies, share ideas, build collaborations, and overcome obstacles. PeDRA recognizes the critical importance of industry collaboration in the research process and hopes that industry representatives are able to engage in as much breakout session time as possible. However, due to the potentially sensitive nature of the discussions taking place, these sessions may be open or closed to industry representatives, for some or all of their scheduled time, at the discretion of the breakout session chair. When participating in a breakout session, industry representatives are expected to engage as learners, listeners, creative scientists, experienced advocates, and active or potential collaborators. In no case, shall a breakout session be a forum for commercial messaging, advertising, promotion, solicitation, or dissemination of clinical trial data. PeDRA reserves the right to ask participants to leave a breakout session if this expectation is not being met.

By checking this box I certify that I have read and understand this statement. Agreeing to this statement is a requirement for any Industry Representative interested in attending the conference. To be eligible to join any open breakout session(s) all attendees must also agree to the PeDRA Confidentiality Agreement near the bottom of this form. Please contact PeDRA's Executive Director, Mike Siegel, with any questions or concerns.

Current Street Address

City

Country

State

State/Province

Province

Postal Code

What type of address is this?

PersonalBusinessOther

Demographics

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 may be shared for strategic purposes.

Please specify your gender:

FemaleMaleNon-binaryI do not wish to provide this information.

With what race(s) do you self-identify? Please select all that apply.

American Indian or Alaska Native	Asian
Black or African American	Hispanic or Latinx
Middle Eastern or Northern African	Native Hawaiian or other Pacific Islander
White	Other - write in
I do not wish to provide this information.

Other - write in race:

Special Events and Activities

Would you like to register for the Early Investigator (EI) Forum taking place on the evening of Thursday, November 9, and the morning of Friday, November 10? Please note that the 2023 EI Forum is closed to students or other trainees prior to graduating from medical school. Students and recent graduates are encouraged to participate in the NextGen Research Forum instead of the EI Forum.

Yes, please follow up with me closer to the conference.No, I'm not interested in attending these sessions.Not sure. Please follow up with me closer to the conference.

Are you interested in joining the NextGen Research Forum taking place on the evening of Thursday, November 9, and the morning of Friday, November 10? This forum is designed to support students and recent graduates and will include networking time, career guidance, and the opportunity to present to a small group.

YesNoNot surePlease note that everyone interested in presenting at the NextGen Research Forum must also separately apply using the NextGen Research Forum application by September 14.

Are you interested in attending the interactive Innovation Forum?

YesNoNot surePlease note that everyone interested in participating in the forum must also separately apply using the Innovation Forum application. Applications for the Innovation Forum are due September 14. Please note, space is limited, and completing the Innovation Forum application does not guarantee acceptance to participate in the Innovation Forum.

PeDRA Members may request 1:1 consultations from expert faculty to discuss individual and/or project needs. Please indicate if you're interested in a consultation.

Biostatistics Consult with Amy Buros Stein, PhD, PeDRA Biostatistician

I'm not interested in scheduling a 1:1 consultation session.Expressing interest in a consultation does not guarantee a 1:1 session during the Annual Conference. Expert consultations will be scheduled according to the order of requests received, preferences listed, and availability of expert faculty. Priority will be given to investigators working on active PeDRA Studies and Early Career Investigators. Attendees invited to participate in a 1:1 consultation may be required to bring pre-prepared materials to the consultation as a condition of participation (e.g. a project outline).

Are you interested in joining a social activity with other conference attendees on the evening of Friday, November 10? Details TBD.

YesNoNot sure

Are you interested in participating in the 3rd Annual Dash for Discovery Fun Run/Walk with other conference attendees on the morning of Saturday, November 11? Dash registration and details can be found at pedraresearch.org/2023-dash-for-discovery/.

YesNoNot sure

Is your child (or children) interested in joining us in person at Camp Wonder at PeDRA 2023? This special session will be hosted by the Children's Skin Disease Foundation to provide fun and interactive activities for kids while parents attend other conference activities.

Yes*NoNot sure*Please also complete the Mini Camp Wonder at PeDRA application HERE.

Please identify which PeDRA's research Focused Study Groups (FSG) you'd like to continue to be a part of or join. Check all FSGs that you'd like to be notified of upcoming meetings.

Acne/HSAD/PsoriasisBirthmarksConnective Tissue DiseaseDrugs & BugsGeneticsHair DisordersNeonatal SkinSkin of Color & Pigmentary DisordersSkin Tumors and Reactions to Cancer Therapies (STARC)Down Syndrome Genetics SubgroupI'm not interested in joining a PeDRA FSG.

Mini Camp Wonder at PeDRA

1st Child's First Name

1st Child's Last Name

1st Child's age on November 9, 2023

Will a second child be attending the conference with you?

YesNo

2nd Child's First Name

2nd Child's Last Name

2nd Child's age on November 9, 2023

To add more than two children please send us an email at conference@pedraresearch.org with the additional child's name and age on November 9, 2023.

Speaker Information

Please provide contact information for your assistant for scheduling and logistics purposes (if applicable).

Please provide your cell phone number to be used for emergency purposes only:

If you haven't already done so, please provide a brief bio to include in the conference program, website, and/or mobile app. (150-word maximum)

If you haven't already done so, please provide a high-quality photo to be used in the conference program, website, and/or mobile app.

PeDRA will make hotel reservations for you at the conference hotel, The Westin Buckhead Atlanta. Please confirm which nights you'll need lodging:

Both Thursday, November 9 and Friday, November 10, 2023Thursday, November 9Friday, November 10I'm either local or not staying in Atlanta overnight and I don't need reservations made for me.Other

Other, please explain:

Please indicate any special dietary needs:

NoneVegetarianOther

Other special dietary needs:

Accessibility and Special Needs

Pursuant to the Americans with Disability Act (ADA), do you and/or the individual(s) you are registering for have any special needs or requirements?

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.

Confidentiality Agreement

PeDRA is committed to protecting confidential and sensitive information related to unpublished research ideas, methods, data, results, and proposals shared at the Annual Conference. Click here to view PeDRA Confidentiality Agreement.

By checking this box I certify that I have read and will abide by PeDRA's Confidentiality Agreement as an attendee at the 2023 Annual Conference. Checking this box is optional, but is a requirement for any attendee interested in joining one or more breakout sessions.

Acknowledgment of Personal Responsibility

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 PeDRA Annual Conference and I understand the risk that I 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 participation in the meeting. 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 and its Meetings Committee, Board of Directors, staff, and contractors from liability should I become ill, directly or indirectly, as a result of my participation in this event.

I acknowledge personal responsibility.I am completing this on behalf of someone else. Please contact the registered attendee for consent.

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

Yes, I want to stay "in the know" on all things PeDRA!	I’m already signed up to receive PeDRA emails.
No, I don't want to receive any communication outside of emails regarding the conference.

Information Sharing

You have the opportunity to share your name, affiliation, and email with other conference attendees through the conference program/app. The information would be visible to all attendees, including PeDRA members, industry and patient partners, non-members, and trainees. *

I acknowledge that my information (name, affiliation, email) will be visible to other PeDRA attendees by using the Conference app.I do not wish to share my information and understand that will mean I will not be using the Conference app to access the Conference agenda, game, and other information and/or activities.

Do you have a complimentary registration code?

Yes, I have a complimentary registration code.No

Do you have a complimentary registration code?

Yes, I have a complimentary registration code.No

Do you have a complimentary registration code?

Yes, I have a complimentary registration code.No

Enter the complimentary registration code here:

This is case-sensitive.

PeDRA will be funding trainees, new investigators, and patient advocates through the travel scholarship program. By adding a donation to your conference registration, you can help ensure more will have an opportunity to receive this crucial funding.

Yes, please add a $20 donation to my registration to help support a resident, fellow, early career investigator, or patient advocate to attend the 2023 PeDRA Annual Conference. No, I do not wish to add a donation to my registration for this purposeYes, but I would like to donate an amount other than $20.Please note that PeDRA is a 501(c)(3) nonprofit organization and your donation will be tax deductible to the extent allowable by law. PeDRA's EIN is 84-2173231.

Please confirm the amount you'd like to donate below.

Please enter the amount in USD. Do not include any symbols (i.e. "$").

Donation comments

Please use this space to add any notes, comments, or dedications for your donation.

Final Total in USD

Payment Information

Name on Card

Card Number

YYYY

Code

Billing Zip code

Billing Email

By clicking "submit" I authorize PeDRA to charge this card for the Final Total in USD. Cards are not kept on file and will only be charged once. No refunds will be provided after October 26, 2023. Please see the PeDRA Annual Conference website for the complete cancellation policy.

Authnet_Hidden_Fields

Member Dollar Amount

Advocacy Discount amount

Industry Partner amount

Speaker Discount amount

Please select your registration category for recordings only:

Note: these prices are available until Thursday, October 6, 2022. Prices will increase at 12:00 AM PT on Friday, October 7. The deadline to register for the 2023 PeDRA Annual Conference is Thursday, October 26.

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Contact Information

Return to Conference Overview

2023 PeDRA Annual Conference Registration Form

Please complete the following form to register for the 2023 PeDRA Annual Conference. We look forward to seeing you in Atlanta!

Send an email to conference@pedraresearch.org or call 971-369-0386 if you have questions along the way or encounter any trouble with the form.

Note that you may save your progress through the form and return later by clicking "Save my progress and resume later" at either the top or bottom of this form.

Registration Details

Attendee Information

Special Events and Activities

Accessibility and Special Needs

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