Conference Registration Form

10th Annual Assistive Technology Conference Registration Form

First Name: Last Name:

Home Address:

City: ST: Zip: County:

Email:

Work Phone: Home Phone: Fax Number:

Employer (if applicable):

Please Check:

Teacher (General Ed)
Teacher (Special Ed)
Administrator/Supervisor
COTA
IT Professional
OT
PT
SLP
Parent/Consumer/Caregiver
Paraprofessional/Technician
Support Coordinator/Case Manager
VR Counselor
Postsecondary Disability Services
Other (specify):

Disability-Related Reasonable Accommodation Needs (request by June 1^st 2007):

Assistive Listening Device

ASL Interpreter

Real Time Captioning (CART)

Large print (20 pt.)

Braille

Disk

Other (specify):

Request Vegetarian Meal - for full conference attendees only

Registration Fees

AT Conference Registration Fee:

Before May 31^th, 2007 After May 31^th, 2007 Copay Discount Code

$180 $230

I would like to only attend the Exhibit Hall on Monday, June 25; from 3:30 - 6:30 - FREE - Please note that this Exhibits Only Registration applies solely to Monday afternoon and will not permit access into the educational sessions of the Conference. (Pre-registration is appreciated.)

Before May 31^th, 2007	After May 31^th, 2007	Copay Discount Code
$180	$230
I would like to only attend the Exhibit Hall on Monday, June 25; from 3:30 - 6:30 - FREE - Please note that this Exhibits Only Registration applies solely to Monday afternoon and will not permit access into the educational sessions of the Conference. (Pre-registration is appreciated.)

Parent/Consumer Scholarships:

A limited number of parent/consumer scholarships for the full conference are available at a reduced fee of $50 on a first come, first served basis. To qualify, call Martha Lewis at 602-728-9534, 800-477-9921 or 602-728-9536 (TTY).

Refund Policy:

There will be a $25 processing fee for all refunds prior to June 8th. No refunds after June 8th.

For more information: contact Martha Lewis at 602-728-9534, 800-477-9921 or martha.lewis@nau.edu