Step 1 of 5 20% Leadership Summit RegistrationStart here to begin your registration for the 2017 NCAN Support Group Leadership Summit by clicking the button below.Valued NCAN Partners / Sponsors Attendee InformationPlease indicate how your name should appear on all meeting materials i.e., name badgeFirst NameMiddleLast NameCredentialsGender- select one -MaleFemaleEmail Office PhoneCell PhoneCommunication Preference- select one -EmailOffice PhoneCell PhoneEmergency Info (in case of accident or illness)NamePhone Support Group InformationIn an effort to better understand the makeup of NCAN Support Groups out in the field, please provide information about your support group below.Support Group NameMailing Address (No P.O. Boxes Please) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country No. of PatientsNo. of CaregiversAre you a registered non-profit?- select one -YesNoWho facilitates your meetings? (check all that apply) Social Worker Nurse Patient Caregiver Paid Facilitator Volunteer Facilitator Do you have any affiliation with a hospital/wellness center?- select one -YesNo Hotel AccommodationsPlease let us know the exact dates you will be checking into and out of the hotel. Please note, three-night stays will be covered for your participation in the meeting. If additional nights are requested, we will be happy to book the extra nights (if available), however they will be booked at the expense of the attendee. Check-In Date Date Format: MM slash DD slash YYYY Check-Out Date Date Format: MM slash DD slash YYYY Room Type- select one -KingDouble/DoubleSpecial Requests / Additional InformationSpecial Needs / Dietary RestrictionsSpecial NeedsDietary Restrictions Travel ProfileNOTE: Complete this section ONLY if you know you have already been approved by NCAN for travel expenses. Non-profits are NOT eligible for travel reimbursements. Complete the following airline preferences - please be as specific as possible. Your itinerary will be based on the information you provide and the meeting parameters. Ticketing is dependent upon airline availability. All flight arrangements should be booked through NCAN. Tickets will not be issued without your verbal or written approval. If you book your flights on your own you will be reimbursed at the basic coach rate.If you are NOT completing this section, simply hit SUBMIT below to complete your registration. Thank You.Transportation Choice- select one -Air: I Need FlightsDriving: I Don't Need FlightsDate of Birth Date Format: MM slash DD slash YYYY For TSA PurposesYour Full Name(as it appears on your photo ID, for TSA purposes):Preferred AirlineFrequent Flyer #DEPARTURE: AirportRETURN: AirportDEPARTURE: Date Date Format: MM slash DD slash YYYY RETURN: Date Date Format: MM slash DD slash YYYY DEPARTURE: Preferred Time and/or Flight #RETURN: Preferred Time and/or Flight #Seat Preference (select one) Aisle Middle Window NCAN recognizes the sensitive nature of the information that may be disclosed on this form and is committed to keeping such information confidential. Therefore, we will not disclose any of the information on this form to anyone other than affiliates who have a reasonable business need to have access to such information.