Special Accommodations Form
Regional Conference

We want to be accommodating------Please return this page with your registration form to let us know what we can do.

I will need the following accommodations in order to participate:

_____ Interpreter
_____ Note taker

_____ Assistive listening device

_____ Open captioning

_____ Large Print

_____ Braille

_____ Audio Cassette

_____ Wheelchair access

_____ Orientation to facility

_____ Special Diet------List: _______________________________________________

_____ Other------List:_____________________________________________________

An assistant will be accompanying me. ____ Yes ____ No____

Please type or print clearly the following requested information:

Name ________________________________________________________________

Organization ___________________________________________________________

Address _______________________________________________________________

City, State, Zip _________________________________________________________

Work Phone (AC) _____________________Home (AC) _______________________

E-mail ________________________________________________________________