AFFILIATE
REGISTRATION  FORM
INSTRUCTIONS


ACCESSING SAFETY INITIATIVE
[MEETING TITLE]
[MEETING LOCATION]
[MEETING DATES]








CONTACT INFORMATION
We will be using the contact information you provide to update our records and communicate any information about the meeting.  Please complete every field.  If you do not have the contact information requested, please note “none” or “N/A” in the space provided.  Please do not leave any field blank. 

ARRIVAL AND DEPARTURE

Please provide us with your best estimate of the date you plan to arrive and depart, and the city/cities from and to which you will be traveling. This will assist our travel agent in making your travel arrangements and it is critical to our internal planning process. If this information changes when you make your air or ground travel arrangements, please notify Hilarie Ashton.   

ACCOMMODATION NEEDS
Please complete every field.  We will use this information to make your hotel reservation.  If you are requesting an ADA or Deaf/HOH room, please indicate the type here.  Feel free to provide any additional information about your preferences in the space provided.

Please keep in mind that requests for bed type (i.e., king, double, etc) are considered preferences and cannot be guaranteed unless it is for accessibility purposes.  If you need a specific type of bed for accessibility or because you are traveling with your PCA, please indicate that in the space provided.




MEETING NEEDS 
To meet your accessibility needs, we need to know the type of reasonable accommodation you require in advance.  While we will make every effort to fulfill reasonable accommodation requests on-site, we cannot guarantee them.  Please complete this section to ensure that your accommodation needs are met.

Please note that reasonable accommodations will be provided during meetings session and during meals.  For referrals for assistance outside of this time, please consult the attached resource sheet or contact Hilarie Ashton at hashton@vera.org.