Transitions

 

This retreat is for young women ages 19-29 with a lupus diagnosis. Registration deadline is June 7, 2019.

 

EACH Attendee must register separately

Please NO children or guests

Attendee Information

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*

Please provide the information listed below so that we may serve you and guide you to the resources best suited to your needs. All information is kept strictly confidential and for use within the LFA Heartland network. Your information will not be sold or given out to third parties.

Birth Date (Date Format: XX/XX/XXXX)*
Year Diagnosed (Date Format: XX/XX/XXXX)
Type of Lupus*
  • Cutaneous Lupus Erythematosus
  • Systemic Lupus Erythematosus
  • Mixed Connective Tissue Disease
Name of Lupus Specialist*
Are you receiving Disability benefits?*
  • No
  • Yes
Please list any/all food allergies
Additional Comments

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