Pacific Rim International Conference on Disability and Diversity | April 25-26, 2016

Registration Form

Hawai’i Convention Center, Honolulu, Hawai’i

PLEASE PRINT – This will be the name that appears on your nametag.

First Name ______

Last Name ______

Organization ______

Street Address 1 ______

Street Address 2 ______

City ______State/Province ______Postal Code ______

Country ______Phone Number ______Fax Number ______

E-mail Address______

Accessibility Requests

Deadline for requests is March 28, 2016. Any requests after this date will be fulfilled if services are available.

Assistive Listening Device: / Braille Materials: / Human Guide for Sight:
Large Print Materials: / Note Taker:
Sign Language Interpreter Services: ASL: Vegetarian Meal: Vegan Meal:

PACIFIC RIM INTERNATIONAL CONFERENCE ON

DISABILITY AND DIVERSITY

April 25-26, 2016

**Conference fee includes 2 days of sessions, continental breakfast, two lunches, and poster evening reception. Registrations received after April 5, 2016 will be charged the On-Site rate.**

Early Bird Registration rates postmarked by January 29, 2016

$295—Regular

$260—Kama‘aina (Hawai‘i Residents; Photo I.D. required)

$235—Student, both days (full-time only - please fax semester schedule)

$185—1 Day registration

Standard Registration rates postmarked January 29, 2016 – April 5, 2016

$350—Regular

$300—Kama‘aina (Hawai‘i Residents; Photo I.D. required)

$245—Student, both days (full-time only - please fax or attach documents)

$215—1 Day registration

On-Site Registration rates after April 5, 2016

$375—All Participants, both days

$240—1 Day registration

Note: Registration for Personal Assistants is essential. Full registration cost is waived. There is a small food-related fee of $115 per person for each conference.

$115—Personal Assistant

Please choose which program book format you would like to receive:

We are offering alternative program book formats in an attempt to go green! Please only check one box.

eBook - Complimentary (will receive link 6-14 days in advance)

PDF - Complimentary (will receive 6-14 days in advance)

Printed Program Book (will receive on-site)

Method of Payment

Checks, Money Orders and Purchase Orders are to be made payable to: RCUH #1324.

Pac Rim Federal Tax ID # 99-0115254. Hawai‘i Department of Education Code 119-183.

Event(s) Attending: Pacific Rim (Both Days) Monday, April 25 Tuesday, April 26

Pre-/Post-Conference Event(s)

Total Amount: $ ______

Check Money Order: ______Credit Card (Fill out next section)

Purchase Order #: ______

Credit Card Information

If emailing form, please DO NOT enter your credit card number below. We will call you to complete the registration process. Alternatively, you may fax this form with complete credit card info to our secure line 808-956-4437.

Check one: MasterCard Visa

Last 4 Digits ______Exp. Date ______3 or 4 Digit Security Code ______

(We will call you for full number) (Listed on the back of card)

Name ______Phone Number ______

(As it appears on the card)

Billing Address 1 ______

Billing Address 2 ______

City ______State/Province ______Postal Code ______Country ______

E-Mail Address ______

Mail, Fax or E-mail

Contact the Registration Desk with any concerns. Call 1-(808) 956-8816.

Mail to: Pac Rim Conference, Center on Disability Studies, 1410 Lower Campus Road, 171F, Honolulu, Hawai‘i 96822. Fax to: 1-(808) 956-4437, or email .

Refunds/Cancellation Policy

All cancellations must be made in writing, mailed and postmarked no later than Friday, February 12, 2016. No refunds will be issued after this date. A processing fee of $40.00 (U.S. dollars) will be assessed for all cancellations. All refund checks will be mailed approximately six to ten weeks after the conclusion of the conference. Mahalo!

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