PCOS Advocacy Day 2019 - Roommate Request Form
PCOS Advocacy Day - March 6-7, 2019

If you would like to share a hotel room or Airbnb with a fellow PCOS Advocacy Day attendee during the event, complete this form and PCOS Challenge will try to find you a match.

Please Complete the Form Below
First Name *
Your answer
Last Name *
Your answer
Organization (If applicable)
If you are participating as part of an organization or professional society, please list your affiliation.
Your answer
Gender *
CONTACT INFORMATION
Email Address *
Your answer
Phone *
Your answer
Facebook Username
Your answer
I give PCOS Challenge permission to share the following contact information with potential matches (check all that apply): *
Required
ADDRESS
Please list your address below and we will also contact you if a lodging travel grant becomes available for advocates from your Congressional district.
Address *
Your answer
Suite/Apartment/Unit
Your answer
City *
Your answer
State or U.S. Territory *
Zip Code *
Your answer
TRAVEL INFORMATION
Travel and Accommodations information may be found on the PCOS Advocacy Day website at https://pcoschallenge.org/pcos-advocacy-day/travel/.
Already have a room? *
If you already have a room, what is the name and address of the hotel or Airbnb?
Your answer
Departure Date *
MM
/
DD
/
YYYY
Arrival Date *
MM
/
DD
/
YYYY
ADDITIONAL COMMENTS
Notes
Your answer
Submit
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