ATIA 2017 Orlando Conference and Exhibition
Pre-Conference Seminars: January 17-18 (Separate fee to participate)
Exhibit Hall Open: Wednesday, January 18 – Saturday, January 21
Conference Sessions: Thursday, January 19 – Saturday, January 21
Caribe Royale All Suites Hotel & Convention Center
Orlando, Florida
ATTENDEE REGISTRATION FORM
Please print clearly or type (this form may be copied for additional registrants.)
First Name: ______
Last Name: ______
Badge Name: ______Position/Title: ______
Company Name: ______
Address: ______
City/State/Zip Code/Country: ______
Phone: ______Fax: ______
E-mail: ______
If you need to be accompanied by an assistant, please enter their name here for a complimentaryassistant badge. Please note: assistant registrants are not eligible for continuing education credit.
Assistant First Name: ______Assistant Last Name: ______
Assistant Email: ______
ATIA may use personal identifiable information collected, such as to help minimize any potential hotel attrition penalties for the association. By registering for the conference you consent to such use. If you have any questions or concerns please contact ATIA at .
___ Check here if you do NOT want to receive e-mails from ATIA Exhibitors and Members with details including special offers or other conference-related materials.
If you have any special needs, accommodations, or dietary requests, please detail your requirements below:
______
______
______
ATTENDEE PROFILE
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Orlando Attendee Registration Form |Page1
1. Please indicate your attendee category (select all that apply):
(A)Accessibility Professional
(B)Advocate
(C)AT Dealer
(D)AT specialist
(E)Consultant
(F)Consumer
(G)Education administrator
(H)Federal Government
(I)Hard of Hearing/Deaf specialist
(J)K-12 educator
(K)Occupational therapist
(L)Parent
(M)Physical therapist
(N)Rehabilitation specialist
(O)RESNA ATP
(P)Speech-language pathologist
(Q)Special education director
(R)University affiliate
(S)Vision specialist
(T)Other (please specify) ______
2. Please indicate what most closely describes your role in purchasing decisions in your organization:
(A) I am the purchasing decision-maker
(B) I approve purchases
(C) I recommend/influence purchasing decisions
(D) I am not involved in purchasing decisions
3. How did you hear about this conference?
(A) ATIA Website (B) AT Vendor (C) Email
(D) Word-of-Mouth (E) Advance Program
(F) Conferences AOTA, ASHA, CSUN, CTG, RESNA, Other
(please specify): ______
(G) Other (please specify): ______
4. Please select conference materials in any of these alternate formats (Limited availability - must be requested by December 16, 2016)
Note: Printed copies of the Braille and Large Print documents will be available at the Accessible Services and Material Desk.
(A)USB with accessible materials including electronic Braille files
(B)Braille Conference Program and Session Grid
(C)Tactile Exhibit Hall Floor Map/Exhibitor List
(D)Large Print Conference Program and Session Grid
(E)Sign interpreter
(F)Other (please specify):
______
5. Have you previously attended an ATIA Conference? Yes No
If yes, please indicate the number of years you have attended an ATIA Conference:
(A) 1 year (B) 2-5 years
(C)More than 5 years (D) More than 10 years
6. Please indicate your interest area(s) (select all that apply):
(A) AAC (Augmentative & Alternative Communication)
(B) Accessibility
(C) Blind/Low Vision
(D) Deaf/Hard of Hearing
(E) Education/Learning
(F) Physical Access/Mobility
(G) Transition/Vocational
(H) Other (please specify)
______
ATIA 2017 #ATIA2017
Orlando Attendee Registration Form |Page1
7. Are you attending the ATIA Annual Conference to earn continuing education credits?
(A) Yes(B) No
If yes, what type of continuing education creditapplies to you? (Check all that apply)
(A) ACVREP(B) AOTA(C) ASHA
(D) Generalist CEUs(E) Other ______
8. Are you interested in attending edcampAccess International at ATIA 2017? By selecting yes, your information will be shared with the organizers of the edcampAccess International unconference.
(A) Yes(B) No
Registration Categories / Fees
Please identify the fees in the proper tier associated with your registration category and include the total below.
Early Bird 9/30/16 / Regular10/1/16 – 12/2/16 / Late
12/3/16 - Onsite
Full Conference Registrationincludes access to the Exhibit Hall, Wednesday Opening Reception and Educational Sessions. Pre-Conference Seminars require an additional registration fee. See page 4 for more information. / $475.00 / $535.00 / $555.00
Group Registration 5+ Attendees (discount 5% per person based on attendee fee) / $451.25 / $508.25 / $527.25
Group Registration 10+ Attendees (discount 10% per person based on attendee fee) / $427.50 / $481.50 / $499.50
Speaker Registration / $375.00 / $555.00
Parent Registration A letter describing your child’s disability must accompany your registration. A letter can be submitted with your registration form. / $237.50 / $267.50 / $277.50
Student Registration Proof of your full-time student status must accompany your registration.A letter can be submitted with your registration form. / $237.50 / $267.50 / $277.50
Exhibit Hall (Wednesday thru Saturday) / $0.00 / $0.00 / $0.00
Single Day Registration
One Day Thursday (includes complimentary Saturday registration). Parents/Students receive 50% off / $300.00
One Day Friday (includes complimentary Saturday registration). Parents/Students receive 50% off / $300.00
One Day Saturday. Parents/Students receive 50% off / $100.00
Pre-paid Lunch Ticket: Select Day/s required:
Tuesday / Wednesday / Thursday / Friday / $17.00 / $17.00 / $17.00 / $17.00
AOTA CEU Fee (Attendance forms provided online) Note: Complimentary CEUs are provided for all sessions. Specialist ACVREP and ASHA CEUs are provided for selected sessions at no cost. / $15.00
ATIA Discount Program
There are a number of discount programs available for the conference. Please note discount offers may not be combined for multiple discounts. Only one discount can be applied per attendee. Please check the discount program before you register for eligibility criteria, available fees and duration to make sure that it is suitable for you.
Alliance Partner 5% discount with CODE: APD7 / $451.25
AOTA Member 10% discount with CODE: AOTA7 / $427.5
Past Attendee 5% discount with CODE: PAD7 / $451.25
Pre-Conference Seminar Information
Pre-Conference Seminars are all-day workshops held on Tuesday, January 17 and Wednesday, January 18, 2017 presented by leading national and international AT professionals. There are separate fees to attend a Pre-Conference Seminar. Pre-Conferences are scheduled from 8:00 AM – 4:00 PM with an hour for lunch from 12:00 – 1:00 PM. Complimentary CEUs are available.
Two Day Pre-Conference Seminar (1/17-1/18/17) / $ 540.00One Day Pre-Conference Seminar (1/18/17) / $ 300.00
Parent/Student Two Day Pre-Conference Seminar (1/17-1/18/17) / $ 378.00
Parent/Student One Day Pre-Conference Seminar (1/18/17) / $ 210.00
Date/Time: Tuesday, January 17 and Wednesday, January 18, 8:00am – 4:00pm
Session Type: Two day
Session Code: PRE-1TWStrand: Sensory Impairment
Session Title: Alternative Technology for People Who Are Blind or Visually Impaired
Speaker: Ike Presley, National Project Manager, American Foundation for the Blind (AFB)
Session Code: PRE-2TWStrand:Assistive Technology for Improved Function
Session Title: AT Bootcamp
Speaker: Kelly Fonner,Education/Assistive Technology Consultant, Kelly Fonner Consulting; Mike Cole, Owner, Use Your Words, PC; Mike Marotta, AT Specialist,Inclusive Technology SolutionsLLC; Brian Wojcik, Assistant Professor, University of Nebraska at Kearney
Session Code: PRE-3TWStrand:Assistive Technology for Improved Function
Session Title: iPAD Boot Camp – Awesome New Apps, Adaptions and Accessories
Speaker: Therese Willkomm, Director of ATinNH, University of New Hampshire
Session Code: PRE-4TWStrand:Augmentative and Alternative Communication
Session Title: More Than Core: AAC Implementation for Early Childhood and Beyond
Speaker: Chris Bugaj, Assistive Technology Trainer, Loudoun County Public Schools;Beth Poss, Montgomery County Public Schools
Session Code: PRE-5TWStrand: Augmentative and Alternative Communication
Session Title: Multi-Modal Communication and Learning Strategies for Children with Significant Challenges
Speaker: Linda Burkhart, Independent Consultant at Linda J. Burkhart
Session Code: PRE-6TWStrand: Leadership
Session Title: Linda Burkhart, Independent Consultant at Linda J. Burkhart
Speaker: Gayl Bowser, M.S.Ed., Independent Consultant, Assistive Technology Collaborations; Denise DeCoste, Ed.D.,Assistive Technology Specialist/Consultant, Accessible Technology Consulting
Date/Time: Wednesday, January 18, 8:00am – 4:00pm
Session Type: One day
Session Code: PRE-7WStrand: Accessibility
Session Title: Accessible Content Management: Systematically Find, Deliver & Use Alternative Materials & Tools
Speaker: Donna McNear, COS, McNear Consulting
Session Code: PRE-8WStrand: Everyday Technology
Session Title: Scaffolds for Successful AT Implementation: Coaching, Gaming, Digitial Badging, Microcredentialing and More!
Speaker: Brian Wojcik, Assistant Professor, University of Nebraska at Kearney
Session Code: PRE-9WStrand: Assistive Technology for Improved Function
Session Title: From UDL to AT: CollaborATively Making Solutions Work for All
Speaker: Matthew Press, OT, MHS, Assistive Technology Coordinator, Peoria Unified School Distric; Judith Schoonover, OT, MEd,Occupational Therapist/Assistive Technology Trainer,Loudoun County Public Schools.
This an AOTA Sponsored Pre-Conference. AOTA members receive 10% discount on registration fees.
Session Code: PRE-10WStrand: Education/Learning
Session Title: Innovative Technologies for Learners with Reading and Other Learning Differences
Speaker: Karen Janowski, Assistive Technology Consultant, EdTech Solutions; Sharon Plante, Eagle Hill Southport
Session Code: PRE-11WStrand: Everyday Technology
Session Title: Google Chrome Bootcamp: 2017 Edition!
Speaker: Mike Marotta, AT Specialist, Inclusive Technology Solutions, LLC
Session Code: PRE-12WStrand: Education/Learning
Session Title: Technology, Autism and Communication!
Speaker: Carol Allen, City Learning Centre
Session Code: PRE-13WStrand: Education/Learning
Session Title: Access in Hand: From Print to Expression
Speaker: Dan Herlihy, Assistive Technology Resource Specialist, Connective Technology Solutions, Inc.
Session Code: PRE-14WStrand: Core Standards: K-12
Session Title: Breaking Out the AT Toolkit: A Hands-On Experience
Speaker: Loreto Dumitrescu, AT Evaluator, NYC Department of Education Center for Assistive Technology, Maricris Formoso-Santos, AT Supervisor, NYC Department of Education Center for Assistive Technology, Lindsey Huntley, Speech Supervisor Center for Assistive Technology, NYC Department of Education Center for Assistive Technology, Mylene Matro, AT Evaluator, NYC Department of Education Center for Assistive Technology
5 WAYS TO REGISTER
ONLINE: FAX: 847-277-7414
EMAIL: TELEPHONE: 847-620-4471
MAIL: ATIA Registration, 8324 Solutions Center, Chicago, IL 60677-8003
PAYMENT INFORMATION: Full payment must accompany registrations.
ATIA Federal ID#: 77-0482095
Check (payable to ATIA)MCVisaAMEXPO (Original purchase order must accompany registration)
Total Fees Due: $ ______Discount Code (if applicable): ______
Check/Card/PO# ______Exp Date ______CVV Code ______
Name on card (please print) ______
Signature: ______
If you submit this form via fax, email, online, or mail, you are agreeing to the cancellation policy and the purchase payment policy.
Cancellation Policy: A full refund will be granted to cancellations made in writing on or before Tuesday, November 1, 2016. Name changes and substitutions are allowed at no fee. Regrettably, no refunds will be given on cancellations received on or after Wednesday, November 2, 2016. Phone cancellations will not be accepted. Written cancellations must be sent by email to or faxed to +1 847-277-7414. Regrettably, no cancellations can be processed after January 22, 2017, after the conclusion of the conference.
Purchase Order Payment Policy: If your organization is required to submit a purchase order for payment, please send your purchase order document with all pages of the registration form. Registrations paid by purchase order are subject to the Cancellation Policy. Purchase order payments are due no later than 30 days after the completion of the conference, by February 22, 2017. Payments received after February 22, 2017, will incur a $75 late payment administrative fee.
If any circumstances or event beyond the control of ATIA causes cancellation of all or any portion of the event, ATIA agrees to refund any portion of the registration fee which ATIA is reimbursed by insurance or other third party and shall not be liable for any other refund or payment arising from the cancellation or for other liability or damages arising from the event.
Please Note: On occasion, an ATIA photographer may take photos of participants at ATIA Orlando 2017, or of people participating in conference functions or activities. Please be aware that these photos are for ATIA’s use only, and may appear in ATIA conference programs, brochures, newsletters, website and other publications and materials. Your attendance constitutes your permission and consent for this photography and subsequent usage.
ATIA 2017 #ATIA2017
Orlando Attendee Registration Form |Page1
ATIA 2017 #ATIA2017
Orlando Attendee Registration Form |Page1