subject_line

Statewide Conference 2018 - Registration Form

Thank you for your interest in attending our Statewide Conference
To ensure your participation, please complete the information below

First name *

Last name *

Email *

Telephone *

Address *

City *

State *

Zip code *

Name of your child *

Age of your child *

Select the option that better describes you *

Parent, professional

Student with school ID

Self-Advocates 16 year old and up

Did you attend last year’s conference? *

Yes

No

Who will cover the registration cost? *

Myself

Regional Center

School Distric

Agency

Regional Center's name? *

Coordinator's name? *

District's name? *

Name of the school in which your child attends? *

Agency's name? *

Name of the person who approved the registration? *

Telephone number of the person who approved the registration? *

Participant’s language? *

In case the presentation is conducted in Spanish, do you need simultaneous interpretation? *

Yes

No

Registration cost for the Annual Conference

	$90 father/mother
	$100 professionals
	$40 Students with valid school ID
	$40 Self-Advocates 16 year old and up

Subtotal Total:

$0.00