* 1. First Name:

* 2. Last Name:

* 3. Title, if applicable:

* 4. Name of Organization, Agency, or Business:

* 5. Mailing address - street number and name:

* 6. City, State, Zip:

* 7. Phone:

* 8. Email:

* 9. Select the option that best describes your work or role in the community:

* 10. Do you need an accommodation?

* 11. If you need an accommodation, please indicate the type of accommodation needed:

* 12. Indicate the afternoon panel discussion you will attend for Session 1, from 1:30-2:45pm:

  Session 1A: Health Care Reform: Access for People with Disabilities Session 1B: Housing Rights: Healthy Living & Aging in Place Session 1C: Education Rights: Technology & Special Needs Students
Session 1

* 13. Indicate the afternoon panel discussion you will attend for Session 2, from 3-4:15pm:

  Session 2A: Health Care Reform: Exchanges and Managed Care Session 2B: Employment Rights: Underemployment of People with Disabilities Session 2C: Education Rights: People with Disabilities in Higher Education
Session 2

* 14. Please check the appropriate registration level:
Scholarships to cover the cost of the Summit's registration are available. For more details, please contact Karina A. Arabolaza, CAP Coordinator, (213)736-1471 or disabilityrightssummit@lls.edu

  Registration
Attorney, Social Workers, HR (For individuals seeking Continuing Education Credits/Units) - $35
Nonprofit Organization, Government Organization, Private Business - $20
Senior, Student, Consumer, General Public - $10

* 15. Continuing Education Units/Credits will be provided to eligible attendees. If you would like MCLE, CEU credit, please complete the following:

* 16. Payment Method:

* 17. Thank you for registering to the 1st Annual Disability Rights Summit. Once you have answered the questions above and click 'Done' below, your registration is complete. (Please note, surveymonkey may direct you to another site or survey which is NOT part of the registration).

T