2018 Underserved Grantee Institute Registration

Underserved Grantee Institute

The Alliance of Local Service Organizations in partnership with the U.S. Department of Justice Office on Violence Against Women invites you to participate in the Underserved Grantee Institute. The Institute will take place October 9th - 11th, 2018 in Chicago, Illinois at the Hyatt Regency Chicago. More information is forthcoming. If you need assistance filling out the registration, please contact us at underservedtaproject@also-chicago.org

Attendees should complete this registration by close of business
Tuesday, August 21st, 2018.

The registration form should be completed by ALL individual(s) in your organization/partnership who will definitely be attending the Underserved Grantee Institute. You may send up to 2 people per grantee. Please consider sending (a) significant MOU partner(s), (b) the grant oversight individual and/or (c) the direct front line/implementation individual. NOTE: If more than 2 people from your grant team (attendance includes MOU organizations) register for the conference, their name(s) will be placed on a waiting list until further information can be provided.

Question Title

* 1. For room booking purposes: please provide anticipated arrival and departure date and time below:

Arrival:

Date

Departure:

Date

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* 2. Contact Information

Prefix:

First Name:

Last Name:

Suffix:

Job Title:

Agency:

Address 1:

Address 2:

City:

State:

Zip:

Phone (xxx.xxx.xxxx):

Extension:

TTY(xxx.xxx.xxxx):

Fax (xxx.xxx.xxxx):

E-mail:

Emergency Contact:

Emergency Number:

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* 3. Which of the following describes your organization regarding the Underserved Grant?

Lead Agency

MOU partner

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* 4. Is all of the above information correct? Please note that this information will be used for all meeting materials (i.e. - name badges, table tents, etc.).

Yes

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* 5. Contact information appears in our meeting materials, including the program. Can we share your contact information with other grant recipients/meeting attendees?

Yes

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* 6. One of ALSO's Technical Assistance (TA) foundations for the Underserved Grant Program is peer to peer learning. Would you be willing to share your program summary with other Underserved grantees at the orientation in order to learn more about the different projects funded under this grant?

Yes

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* 7. Do you have any suggestions for structure or content related to agenda programmatic development? Are there any topics related to your deliverables within the Underserved Program that you would like to see covered (technical assistance around data collection, policies and procedures, outreach methods etc.)? If so, please describe.

We value access and safety and strive to make our meetings accessible and welcoming to all participants. Please fill out the following information to help us provide accommodations that give everyone an opportunity to fully participate in this year's meeting.

Question Title

* 8. Please select any accommodations you require for meeting sessions. In order for services to be as appropriate as possible, please be as specific as possible. Every effort will be made to accommodate requests made in advance. On-site requests cannot be guaranteed.

None required

American Sign Language Interpreter

Close vision/Low vision Interpreter

Cued Speech

Electronic copies of meeting materials in advance

Hard copies of materials on-site

Electronic text file of materials (available at the meeting)

Materials in Braille

Materials in font over 14 pt (please indicate the font size in the "other" box)

Signed English

Certified/ Deaf Interpreter

Assistive Listening Devices

CART

C-PRINT

Simple Language Program

Simultaneous Communication

Wheelchair access

Oral/English

Other (please specify)

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* 9. Please specify any special hotel accommodations you require. In order for services to be as appropriate as possible, please be as specific as possible. Every effort will be made to accommodate requests made in advance. On-site requests cannot be guaranteed.

ADA Room with Roll-In Shower and double beds

ADA Room with Roll-In Shower and king bed

ADA Room with Tub and Shower and double bed

ADA Room with Tub and Shower and king bed

Chemical Free Room

Room Accessible for Deaf/Hard-of-Hearing with ADA Deaf Kits

Room Preparation for Infant (i.e. - a crib)

None of the above

If necessary, please provide further details describing your preferred accomodations:

If you have a disability that requires a Personal Care Attendant (PCA) or Personal Assistant (PA) to accompany you on your travel, please contact the Underserved TA Project Team at underservedtaproject@also-chicago.org or call 773-235-5705 extension 212 to discuss accommodations.

Every effort will be made to ensure access to this meeting; please allow us sufficient time to meet your request for auxiliary aids and services by submitting your registration by August 21st, 2018. Please contact the Underserved TA Project Team at underservedtaproject@also-chicago.org if you need referrals for assistance outside of the meeting and if you have any questions.

Before pressing the “Done” button at the bottom of the registration, please print the page for your records as you will not be able to access the page once you have pressed the “Done” button. After you have selected your team of attendees and have registered, please book travel immediately in order to take advantage of least expensive flight options. The Underserved TA Project page on the ALSO website will be updated to reflect the most current information about this meeting and you will be notified via email about these updates. Please be on the lookout for additional information about the hotel, transportation, meeting agenda and meeting materials. Do not book hotel reservations until receiving further instructions from ALSO to do so.

Thank you for taking the time to complete this registration form!
If you have any questions please contact the Underserved TA Team at
underservedtaproject@also-chicago.org