Technology and Persons with Disabilities Conference
Please complete one form per registrant. You may photocopy this form for additional registrants.
List your name and address as you would like them to appear on your name badge and on any correspondence.
Ways To Register: |
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| Email: conference@csun.edu | Mail: Attn: TECH/DIS CONF-Participant | |
| Phone: (818) 677-2578 | CSUN, Center on Disabilities | |
| Fax: (818) 677-4929 | 18111 Nordhoff Street | |
| Northridge, CA 91330-8340 | ||
First Name ______________________________ Last Name: ______________________________
Organization: ____________________________________________________________________
Street Address: ___________________________________________________________________
City: ____________________________________________________________________________
State/Province/Region: ____________________________________________________________
Zip/Postal code: __________________________________________________________________
Country: _________________________________________________________________________
Day Phone: _______________________________________________________________________
Fax: _____________________________________________________________________________
Email: ___________________________________________________________________________
The Center on Disabilities provides contact data (names and mailing addresses) to
third parties who wish to promote relevant products, services and other opportunities which
may be of interest to you.
_____ Check here to remove your information from this list.
| CONFERENCE REGISTRTION FEES (Please check all that apply) | Early Paid by Feb. 20, 2006 |
Regular Fee Paid after Feb. 20, 2006 |
Total Fee |
|---|---|---|---|
| Preconference Workshops of Monday, March 20, 2006 Check ONE: __M-1 __M-2 __M-3 __M-4 __M5 __M-6 __M-7 |
$249 Full-Day $150 Half-Day |
$279 Full Day $180 Half-Day |
$_____ |
| Preconference Workshops of Tuesday, March 15, 2005 Check ONE: __T-1 __T-2 __T-3 __T-4 __T-5 __T-6 __T7 |
$249 Full $150 Half |
$279 Paid after Feb. 14, 2005 |
$_____ |
|
_____General Sessions Conference Package |
$399 |
$449 |
$_____ |
| Per Day Attendance | |||
| _____Wednesday, March 22, 2006 (Keynote Address, General Sessions and Opening of Exhibits) |
$259 |
$299 |
|
| _____Thursday, March 23, 2006 (General Sessions and Exhibit Halls) |
$249 |
$289 |
|
| _____Friday, March 24, 2006 (General Sessions and Exhibit Halls) |
$249 |
$289 |
|
| _____Saturday, March 25, 2006 (General Sessions and Exhibit Halls) |
$179 |
$239 |
$_____ |
| Total Registration | $_____ |
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Accessibility Services:
__ Assistive Listening Device
__ Real-Time Captioning (CART)
__ Sign Language Interpreter
__ Adapted Program (check one of 4 with X before it):__Braille __Disk(ASCII) __Large Print __ Daisy CD
There is no fee for authorized care providers accompanying paid attendees.
Care Provider attending with me:
(first name, last name) _________________________________
Method of Payment:
Full payment must be received in our office on or before February 20, 2006 to qualify for the
EARLY discount rate. Please make check payable to CSUN.
All cancellations are subject to a $50 processing fee.