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Lupus Patient Education Class - Registration
Pick the Patient Education Classes you would like to register with. with the Lupus Foundation of Northern California. If you would like to register offline, please return to LFNC.org or call 408-954-8600.
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* Indicates required question
I/we would like to attend the following class:
*
choose the class you want to sign up for.
February 27, 2016
May 14, 2016
August 13, 2016
November 12, 2016
First Name
*
Your answer
Last Name
*
Your answer
Email Address
*
Your answer
Phone:
*
Your answer
Gender
*
Female
Male
Address
*
Your answer
City, State, Zip
*
Your answer
LUPUS PATIENT INFORMATION (OPTIONAL)
Are you a lupus patient?
Yes
No
Clear selection
If not, please describe your relationship to Lupus.
Your answer
LUPUS CLASS INFORMATION
Will you be attending with someone else?
Yes
No
Clear selection
If yes, how many guests?
Your answer
Please list the names of the guests you will bring (additional participants):
Please list one name per line and optionally indicate whether each is a lupus patient.
Your answer
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