2024 Camp Wonder Form Mini Camp Wonder Registration Form Mini Camp Wonder at PeDRA will be held at the Sheraton Phoenix Downtown Hotel on the afternoon of Friday, October 25, 2024. Camp will be run by the Children's Skin Disease Foundation with support from medical student volunteers. Registration for Mini Camp Wonder at the PeDRA Conference must be completed by a parent or guardian of the camper no later than 3PM local time on Friday, October 25, 2024.This form must be completed by a parent or guardian over the age of eighteen (18). Permission to Participate By checking the box, I hereby grant permission for my child(ren) to participate in Mini Camp Wonder at PeDRA. Acknowledgement of age By checking the box, I hereby acknowledge that the Mini Camp Wonder at PeDRA registered camper(s) is over the age of 6 and under the age of 18. Children that will be 5 years old on October 25, 2024, 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 October 25, 2024Please select... 5 6 7 8 9 10 11 12 13 14 15 16 17 Camper's Preferred Name: Please indicate below the camper's desired pronouns to be listed on their name badge.Please select... He, him, his She, her, hers They, them, theirs Other Camper prefers not to have pronouns listed on the conference badge. 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 camper's gender identity:FemaleMaleNon-binaryOtherI do not wish to provide this information. With what race(s) does the camper's 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: Accessibility and Special NeedsPursuant to the Americans with Disability Act (ADA), does this camper have any special needs or requirements? Do you need to register a second camper? YesNo Please indicate below the camper's desired pronouns to be listed on their name badge.Please select... He, him, his She, her, hers They, them, theirs Other Camper prefers not to have pronouns listed on the conference badge. Second Camper's First Name Second Camper's Last Name Only last initials will be used on the badges. Second Camper's age on October 25, 2024Please select... 5 6 7 8 9 10 11 12 13 14 15 16 17 Second Camper's Preferred Name: 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 camper's gender identity:FemaleMaleNon-binaryOtherI do not wish to provide this information. With what race(s) does the camper's 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: Accessibility and Special NeedsPursuant to the Americans with Disability Act (ADA), does this camper have any special needs or requirements? Do you need to add a third camper?YesNo Please indicate below the camper's desired pronouns to be listed on their name badge.Please select... He, him, his She, her, hers They, them, theirs Other Camper prefers not to have pronouns listed on the conference badge. Third Camper's First Name Third Camper's Last Name Only last initials will be used on the badges. Third Camper's age on October 25, 2024Please select... 5 6 7 8 9 10 11 12 13 14 15 16 17 Third Camper's Preferred Name: 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 camper's gender identity:FemaleMaleNon-binaryOtherI do not wish to provide this information. With what race(s) does the camper's 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: Accessibility and Special NeedsPursuant to the Americans with Disability Act (ADA), does this camper have any special needs or requirements? Parent or Guardian's First Name Parent or Guardian's Last Name Parent or Guardian's Email Parent or Guardian's Emergency Contact Phone Number. If applicable, please provide the name of the organization or patient community with which you are involved: Current Street Address City CountryPlease select... Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d ' Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino São Tomé and Prìncipe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands ( British ) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia 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 Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau State/Province ProvincePlease select... Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code What type of address is this?PersonalBusinessOther Photography and Videography PeDRA may capture photographs and video during the 2024 Annual Conference. By this release, I consent to the recording, videotaping, or photographing of my camper's 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 camper's 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 camper's likeness, voice, and name. By this release, I consent to the use of my camper's 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 campers likeness, voice, and name in such media.I am over eighteen (18) years of age and represent that I am the parent or guardian of the camper(s) for whom i am registering. I hereby consent to the foregoing on his/her/their behalf. I AgreeI do not agree, however, I acknowledge having read this Photography and Videography Release that my camper's likeness and voice 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. Please indicate any special dietary needs: NoneKosherVegetarianOther Other special dietary needs: Acknowledgement of Personal Responsibility PeDRA is committed to providing a safe and healthy environment for all conference attendees, exhibitors, partners, and the administrative team. Click here to view the PeDRA Acknowledgement of Responsibility. With my response below, I release PeDRA and its Meeting Committee, Board of Directors, staff, and contractors from liability should I or my camper(s) become ill, directly or indirectly, as a result of my participation in this event.I am 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 accept personal responsibility for myself and my camper(s). In addition to conference updates, do you wish to receive regular updates from PeDRA via email? Yes No Any additional information you'd like to provide about your camper(s)? Will the parent or guardian also be joining us in person for the 2024 PeDRA Annual Conference? YesNoIf yes, in addition to completing this form, please click here to register for the Conference. 2024 PeDRA Annual Conference Travel Scholarships Mini Camp Wonder is free, however PeDRA is proud to offer Travel Scholarships to community members and campers to help offset the cost of travel to attend the event in Phoenix. Scholarships will be awarded following an application and competitive review process, depending on the availability of funds and merit of the applications received. For yourself or camper(s) to be considered, please submit your application before 11:59PM PT on Thursday, August 1, 2024. Click here to apply.Family members are defined as a parent or a guardian of a 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. Contact Information Return to Conference Overview
