We look forward to seeing you at the Conference!

You are required to respond to all registration prompts with an asterisk * . If you need assistance completing this form, please contact Jenny Bopp, Operations Director with the Florida Independent Living Council at 850-488-5624.
Out of State Conference Attendees

There is a registration fee of $100 per person to attend the conference. Please contact Jenny Bopp, Operations Director with the Florida Independent Living Council at 850-488-5624 or Jenny@floridasilc.org to make payment arrangements.

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* First Name

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* Last Name

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* Position

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* Name of your organization

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* Phone Number

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* E-mail

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* I am a Presenter
(If you are a presenter, please enter yes in the space provided below. If you are not a presenter leave the space blank.)

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* County
(If you are not from Florida please enter your state.)

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* I will attend LUNCH on May 16.
(Please respond: Yes or No.)

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* I will attend LUNCH on May 17.
(Please respond: Yes or No.)

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* I require a REASONABLE ACCOMMODATION to participate.
(Please Indicate: None, CART, ASL Interpreter or indicate other.)

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* Food Allergies/Dietary Restrictions
 (Please Indicate: None, Vegetarian, Vegan, Gluten Free, Other.)

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* I will attend the CONFERENCE on May 16.
(Please respond: Yes or No.)

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* I will attend the CONFERENCE on May 17.
(Please respond: Yes or No.)

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* I require ALTERNATIVE FORMATS to participate.
(Please Indicate: None, Braille, Large Print, Electronic Formats or indicate other.)

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