Center on Disabilities Conference Scholarship Application

21st Annual International Conference
Technology and Persons with Disabilities
March 20-25, 2006 ~ Los Angeles, CA

2006 Conference ~ Scholarship Application

Name:_____________________________________________________________________________________________________
Organization:_______________________________________________________________________________________________
Address:___________________________________________________________________________________________________
City:______________________________________State:_______________Zip:_________________________________________
Phone:_______________________Fax:_____________________Email:___________________________________________________

____ Do not include in 3rd party mailing lists

1. Are you an individual with a disability?	____Yes	____No
Disability_______________________________________
2. Are you the guardian of a person with a disability?	____Yes	____No
Name of person with a disability:__________________________
His/Her Disability:________________________________
Your relationship to the person with a disability:_____________________
3. Are you currently employed?	____Yes	____No	____ Full Time	____ Part Time
4. Are you/your dependent a Department of Rehabilitation client?	____Yes	____No
5. Have you attended the CSUN conference before?	____Yes	____No
If so, what year(s)?_______________________________
6. Have you received a scholarship before?	____Yes	____No
If so, what year(s)?_______________________________

The deadline for scholarship applications is February 3, 2006.

___ General Session Package (does not include Preconference)
Includes all the activities of March 22-25, 2006: Keynote Address, more than 300 General Sessions, and entrance into the Exhibit Halls any time during exhibit hours.

Conference Fees Waved $399

Accessibility Services:
__ Assistive Listening Device
__ Real Time Captioning (CART)
__ Sign Language Interpreter
__ Adapted Program: ____ Braille ____ Large Print ____ Disk (ASCII) ____ DAISY CD

Care provider attending with me (first name, last name) ________________________________________________

Signature:________________________________________________ Date:_________________________