HAWAII COPD EDUCATION DAY REGISTRATION FORM

http://hawaiicopd.org/


Your Information:

YOUR FIRST NAME
YOUR LAST NAME
PLEASE INPUT YOUR EMAIL ADDRESS
PLEASE ENTER YOUR PHONE NUMBER HERE
*Call 808-699-9839 no later than August 20th if anything is needed.
*Please explain how you found out about the Hawaii COPD Education Day Program
*This is not required

Additional Guests

ADDITIONAL GUEST FIRST NAME
ADDITIONAL GUEST LAST NAME
PLEASE INPUT ADDITIONAL GUEST EMAIL ADDRESS
PLEASE ENTER GUEST PHONE NUMBER HERE

***By registering, I hereby grant full permission to Hawaii COPD Coalition to use any photographs, videotapes, or any other record of this event.

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