2015 DISABILITY POLICY SEMINAR REGISTRATION FORM (First & Last Name will be used for name badge.) Name (First & Last)____________________________________________________________________________________ Agency/Organization___________________________________________________________________________________ Street Address________________________________________________________________________________________ City _________________________________ State ____________________ Zip___________________________________ Phone (_____) _______________ E-mail Address ____________________________________________________________ (An e-mail address is required to receive a registration confirmation.) Is this your first time attending the Disability Policy Seminar? ____ Yes ____ No Primary affiliation (select one): The Arc AAIDD AUCD UCP NACDD SABE Sibling Leadership Network Other affiliations (check all that apply): The Arc AAIDD AUCD UCP NACDD Other _______________________________ SABE Sibling Leadership Network How did you hear about the event? E-mail Other _______________________________ Social Media Disability Scoop *I will need the following accommodations in order to participate: ASL Interpreter Assistive listening device Captioning Large print Braille Other – Please explain_____________________________________________ NONE Word of Mouth USB with materials * We ask that requests are submitted on or before March 13, 2015. We cannot guarantee accommodations for requests received with less than 30 days-notice. I do not want my name and e-mail included on the state-by-state attendees list posted on the web. On or before 3/13 REGISTRATION FEES Attendee Self-Advocate Student Trainee Fellow Personal Care Attendant [Attendee name: _______________________________] One-Day Monday One-Day Tuesday Fee includes: Materials, Continental Breakfast (4/13 & 4/14), Lunch (4/14), Afternoon Refreshment Break and Reception. After 3/13 & On-Site $335.00 $250.00 $135.00 $200.00 $385.00 $275.00 $135.00 250.00 TOTAL: $_________ PAYMENT INFORMATION Check (Payable to The Arc) Visa MC Amex Name: Exp Date: Credit Card #: Signature: Mail check & form to: The Arc of the United States Attn: Event Registration 1825 K Street NW, Suite 1200 | Washington, DC 20006 Fax form to: (919-782-5131) Scan and email form to: [email protected] Cancellation/Refund Policy/ Substitution Policy Cancellation and refund requests must be made in writing by March 27, 2015. A refund of the full fee, minus a $25 administrative fee, will be given for cancellations received by that date. Submit all requests to Robin Powers via email at [email protected]. Refunds will not be given for no-shows. Substitutions are gladly accepted. To transfer your full registration prior to the seminar, please submit a written request to [email protected]. Onsite transfers must be accompanied with proof of the original confirmation letter. Only one transfer is permitted per original registrant. The individual submitting the transfer request is responsible for all financial obligations (any balance due) associated with that substitution. Questions? Please e-mail us at [email protected] or call 919.782.9417.