PFMO 2015 Conference Registration Form

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* 1. Please provide the following information:

Name: (required) *

PF Chapter or Company:

Address: (required) *

City/Town: (required) *

State: (required) *

ZIP: (required) *

County you live in:

Email Address: *

Phone Number: *

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* 2. How are you connected to the self-advocacy movement? (Check ALL that apply)

Belong to a "Local" or "State" self-advocacy group

Person with a disability

Adviser to a Local or State self-advocacy group

Family member of a person with a disability

Professional in the disability field (includes PCA/direct care person)

Other (please specify)

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* 3. If you require written materials in an alternate format, please select your preferred format:

Braille

Large Print

Electronic Format

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* 4. Do you require a sign language interpreter?

Yes

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* 5. Do you have any special dietary needs?

None

Vegetarian

Kosher

Gluten-free

Other (please specify)

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* 6. Do you have any other requirements that we need to know about?

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* 7. Please select your T-shirt size:

Small

Medium

Large

X-Large

XX-Large

XXX-Large

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* 8. Please select the breakout topic you are planning to attend in Breakout Session 1: (Saturday Afternoon-2:15 to 3:30)

A. Alternatives to Guardianship: Learn Your Rights

B. Clean Up Your Act! It's Not Personal...It's Professional

C. How One Chapter Conducts Its Meetings

D. What is a Good Life?

E. How to Get a Job and Keep It

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* 9. Please select the breakout topic you are planning to attend in Breakout Session 2: (Saturday Afternoon-3:45 to 5:00)

F. A Home to Call Your Own

G. Preparing for a Disaster: Are You Ready

H. All About Assistive Technology

I. I'm Human, You're Human: Go Tell the World

J. People with Disabilities and the Law

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* 10. Please select the breakout topic you are planning to attend in Breakout Session 3: (Sunday Morning-9:00 to 10:15)

K. Oral Health & Your Body

L. Healthy Relationships: Creating a Plan

M. Self-Advocacy at the Local Level

N. Planning for a Good Life

O. Asset Building: Why It's Important & How to Do It

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* 11. REGISTRATION OPTIONS & FEES

Registering by APRIL 7:

- FULL REGISTRATION - $95
(includes conference materials, all sessions, 3 meals on Saturday, Sunday brunch, and T-shirt)

- SATURDAY ONLY - $75
(includes materials, Saturday sessions and meals, and T-shirt)

- SUNDAY ONLY - $50
(includes materials, Sunday sessions and brunch, and T-shirt)

IMPORTANT NOTES:
If registering after APRIL 7, T-shirts will cost $10, and may not be available in your size.
After APRIL 21, no meals will be included with your registration. Same fees apply.

NO REFUNDS after APRIL 21.

Please select your registration choice below:

Full Registration - $95

Saturday Only Registration - $75

Sunday Only Registration - $50