2024 Physical Therapists Conference Flight and Hotel Information

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HTC Name*

If your HTC name isn't listed above, please enter it in the box below

==== TRAVELER(S) INFORMATION ====

Name (Note: the name entered here must exactly match with the Government ID you use for traveling)*

Email Address*

Phone*

Emergency Contact*

First Last

Phone*

Relationship*

I Only Need A Hotel Room*

Yes

Date of Birth

Hotel Check In Date

Hotel Check Out Date

Hidden

Hotel Check In Date

Hidden

Hotel Check Out Date

Flight Departure Date

Flight Departure City

Flight Return Date

Flight Return City

Flight Seat Preference

Aisle

Window

Preferred Outgoing Flight - Airline

Preferred Outgoing Flight - Flight #

Preferred Return Flight - Airline

Preferred Return Flight - Flight #

Frequent Flyer Program (Airline & Number)

TSA Precheck ID

Hotel Room Preference

1 Bed

2 Beds

Handicap Accessible

Dietary Preferences / Allergies

Notice of filming and photography - Upon attending any Hemophilia Alliance meetings or special events, you consent to interview(s), photography, audio recording, video recording and Hemophilia Alliance release, publication, exhibition or reproduction for promotional purposes, advertising, inclusion on websites, social media, or any other purpose by Hemophilia Alliance and its employees or affiliates.

Consent*

Yes - I consent to the filming and photography notice

No - please do not include me in any photos or videos

Name

This field is for validation purposes and should be left unchanged.

Please contact Theresa Parker if you have questions at theresa@hemoalliance.org or 727.688.2568.