Statewide Conference
Registration Form
Self-Advocates of Indiana, Inc.
Registrations will be accepted by mail until August 1, 2006.
1. Please print out this page or
print the registration form in PDF format.
2. Complete the information requested on the form.
3. Make out your check to Self-Advocates of Indiana.
4. Send your registration form, check or money order to:Conference
Center on Aging and Community
Indiana Institute on Disability and Community
2853 East 10th Street, Bloomington IN 47408
Registration forms are also available by mail. To request a
paper form or to get more information, please
e-mail Maribeth Mooney or call her at 1-800-825-4733
(Indiana only) or 812-856-5443.
Each person, including staff and individual PCA's (Personal Care Attendant), planning to attend the conference must complete a separate registration form and mail it in with their payment.
Cancellations
All cancellation requests must be made in writing. Cancellations
are subject to a $10 administration fee.
We regret that refunds cannot be offered for “no shows” or for cancellations received after August 1. You may send a substitute
in your place if you are unable to come.
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2006 Statewide Self-Advocacy Conference Registration
Please Print
Name _______________________________________________
Please check one:
__ I am a self-advocate
__I am staff accompanying self-advocates
__ I am a family member
__ I am a PCA for a person
Address ______________________________________________
City______________________ State__________ Zip __________
Home telephone number with area code_____________________
Agency affiliation, if applicable ____________________________
Agency contact person and phone number ___________________
_____________________________________________________
Agency address ________________________________________
_____________________________County___________________
Scholarships
A limited number of scholarships are available on a first-come,
first-served basis to individuals or households with dependents receiving Indiana SSI, SSDI or TANF.
The scholarships are for the conference registration fee that includes all four meals. The scholarships do not apply to the overnight hotel rooms. Applicants requesting a scholarship must send a $10 check or money order with their registration form. Checks will be returned if the scholarship cannot be granted.
_____I am requesting a scholarship; enclosed is my $10 check
or money order.
Special Accommodations
If you are requesting any of the following accommodations, your registration form and payment must be received by August 1, 2006. Special accommodations for late registrations cannot be guaranteed.
_____ I need a sign language interpreter
_____ I need wheelchair access
_____ I have a service animal(s)
_____ I need large-print or Braille (tell us which)____________________ I have special dietary needs (please explain):
_____________________________________________________
_____ Other special needs (please explain):
_____________________________________________________
Fees and Payment InformationPlease mail your form and check to the address at the top of the page.
Self-advocates, staff and individual PCA's:
Conference fee is $85 per person.
Families
Conference fees for families are as follows:
1. A family member who will attend the whole conference with their self-advocate: $85 per person.
2. A family member who will attend Thursday evening only for dinner and dance: $15
3. A family member who will attend Friday only: $60 (breakfast and lunch provided)
4. A family member who will attend both Thursday evening and Friday all day: $75 (Thursday dinner, Friday breakfast and lunch)
PLEASE NOTE! Make checks out to
Self-Advocates of Indiana, Inc.Thank You
