Sample Conference Registration Form

Sample Conference Registration Form

Industry Trends in Portable Breakfast Foods September 21-22

At the Omlet Chalet in Bagelburg, USA

Name: ______Title: ______

Institution/Business: ______

Address: ______Phone: ______

______Zip: ______

Lodging Disability Accommodation Needs:

_____ Accessible room: / _____ One bed / _____ Two beds
_____ TTD/text telephone / _____ Television decoders / _____ Visual alarm
_____ Widened doorways / _____ Handrails in bathroom / _____ Shower chair or bench
_____ Lift-equipped transport / _____ Non-smoking room / _____ Room near elevator
_____ Dietary restrictions (explain) ______
_____ I am driving an adapted van to the conference, need van accessible parking.
_____ Other (explain) ______

To participate in the program I will need: (To ensure your request is fulfilled, registration MUST be received by August 21)

_____ Lift-equipped transportation between lodging site and conference site

_____ Printed materials: _____ Braille _____ Large print

_____ Audio taped materials

_____ Materials on computer disk _____Macintosh _____ Windows

_____ Interpreter: _____ ASL _____ Oral _____ Voice _____ Signed English

_____ Note taker _____ Reader

_____ ALD/Assistive Listening Device (please specify) ______

_____ Orientation & Mobility Specialist for conference site and guest rooms

_____ Information for users of service animals

_____ Sighted guides for assistance to/from specific sessions

_____ Other conference accommodation (explain) ______