New Underserved Grantee Orientation 2017

New Underserved Grantee Orientation

The Alliance of Local Service Organizations and the U.S. Department of Justice Office on Violence Against Women invites you to participate in the New Underserved Grantee Orientation on January 31st - February 2nd, 2017 in St. Paul/Minneapolis, Minnesota.

This orientation is being held to provide participants with relevant content pertinent to the Office on Violence Against Women Underserved Grant Program. During the conference we will address overarching themes articulated by Underserved Grantees on the Welcome and Consultations Calls from November/December 2016.

Underserved
New Grantee Orientation
January 31st-February 2nd 2017

Attendees should complete this survey by
Wednesday, December 14th 2016.

The registration form should be completed by ALL individual(s) in your organization/partnership who will definitely be attending the New Grantee Orientation. 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 3 people from your grant team (attendance includes MOU organizations) register for the conference, their name(s) will be placed on a waiting list until it is finalized.

Question Title

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

Arrival:

Date

Departure:

Date

Question Title

* 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:

Question Title

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

Lead Agency

MOU partner

Question Title

* 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

Question Title

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

Yes

Question Title

* 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

* 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)

Question Title

* 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 Zarena Leblanc at 773.235.5705 extension 12 or zleblanc@also-chicago.org 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 responding December 14th, 2016. Please contact us if you need referrals for assistance outside of the meeting. Please contact Zarena Leblanc with any questions.

Before pressing the “Done” button at the bottom of the survey, 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 take advantage of least expensive flight options. The Underserved Grant 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, ground transportation, meeting agenda and meeting materials.

Thank you for taking the time to complete this registration form!
If you have any questions please contact Zarena Leblanc at 773-235-5705, extension 12.
You can also send questions or comments to:
zleblanc@also-chicago.org