Speaker Registration Form

Every speaker and panelist, including exhibitors who are making presentations, must register for the conference. Every speaker pays the Speaker's Reduced Conference Registration Fee as stated in the Call For Papers, Conditions of Presentations, item 7.

Ways To Register: (please print this page, fill out form, and submit by)
Email:	conference@csun.edu
Phone:	(818) 677-2578
Fax:	(818) 677-4929
Mail:	CONF - Speaker Center on Disabilities California State University, Northridge 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.

FEE SCHEDULE	Discounted Fee	Regular Fee	Total Fee
X Speaker's Reduced Conference Registration Fee Includes all the activities of March 22-25, 2006: Keynote Address, General Sessions, and entrance into Exhibit Halls during exhibit hours.	$349 Paid by Jan. 10, 2006	$379 Paid after Jan. 10, 2006	$_____
*Additional Fees (Check all that apply)*
Preconference Workshops of Monday, March 20, 2006 Check preference(s): __M-1 __M-2 __M-3 __M-4 __M-5 __M-6 __M-7	$249 Full-Day $150 Half-Day Paid by Feb. 20, 2006	$279 Full-Day $180 Half-Day Paid after Feb. 20, 2006	$_____
Preconference Workshops of Tuesday, March 21, 2006 Check preference(s): __T-1 __T-2 __T-3 __T-4 __T-5 __T-6 __T-7	$249 Full-Day $150 Half-Day Paid by Feb. 20, 2006	$279 Full-Day $180 Half-Day Paid after Feb. 20, 2006	$_____
Total Registration $______

Accessibility Services:

__ Assistive Listening Device
__ Real-Time Captioning (CART)
__ Sign Language Interpreter
__ Adapted Program (check one):__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 at CSUN no later than January 10, 2006 to qualify for the discounted speaker rate. Please make check payable to CSUN.

__ Check enclosed for $__________________
__ Charge to my: __MASTERCARD __VISA __AMERICAN EXPRESS
Card #________________________________________ Expiration Date _______________
Card Holder Name(print): __________________________________________________
Signature: ________________________________________________________________