PARTICIPANT 
REGISTRATION  FORM
DEADLINE: [XXXXXX]
*NO LATE REGISTRATIONS WILL BE ACCEPTED

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

	
Please answer all questions completely.
We are looking forward to meeting with you in [XXXXXX]!

ARE YOU A(N):  (CHECK ALL THAT APPLY)
?	Grantee
?	Personal Care Attendant 
?	Project Director
?	Other: ________________________________


CONTACT INFORMATION
   Name		  Title	
   Agency	
   Address	
   City		 State		Zip Code	
   Phone		TTY		Fax	
   E-mail	

   Emergency contact person 
   and contact information: 	
	

ARE YOU TRAVELLING WITH A: 
?	Personal Care Attendant (if yes, please complete a separate registration form for PCA)
?	Service Animal
?	None of the above


ARRIVAL AND DEPARTURE
* You are responsible for making your own hotel reservations; however, we need to know when you will be arriving and departing as part of our internal planning process.  

Expected Arrival Date and Time: ______________________________________

Expected Departure Date and Time: ___________________________________


DIETARY NEEDS
*A continental breakfast will be served; however, please note that lunch each day will be on your own.  
?	Vegetarian
?	Vegan
?	Allergies: _______________________________________________________

?	Other: _________________________________________________________


ACCOMMODATION PREFERENCES
* You are responsible for making your own hotel reservations; however, this information allows us to ensure that your accessible room request is met.  Please see your instruction sheet for more details. 

ACCOMMODATION NEEDS

?	ADA compliant room with roll-in shower
?	ADA compliant room with tub and chair
?	Room accessible for persons who are Deaf/hard-of-hearing
?	Other:  ________________________________________________________________ 
    ________________________________________________________________ 



MEETING NEEDS 
Select any accessibility accommodations you require for the meeting sessions below.  Please be as specific as possible. Please note that every effort will be made to accommodate advance requests; on-site requests cannot be guaranteed.

Interpreting Needs
?	American Sign Language (ASL)   
?	Cued Speech
?	Oral/English Speaking
?	Signed English
?	Simultaneous Communication
?	Other: ____________________________________________

Materials 
*please note that hard copies of all materials will be distributed at the meeting
?	Electronic text file
?	Electronic copy in advance 
?	Hard copy in advance 

Alternative Formats
?	Braille
?	Large font
?	Simple language program

Other

Please inform us of any additional accommodations you require for the meeting sessions.  Be as specific as possible. 






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.  





PLEASE RETURN THIS FORM IMMEDIATELY TO: HILARIE ASHTON  
BY FAX AT (212) 941-9407 OR EMAIL AT HASHTON@VERA.ORG

































































































PLEASE RETURN THIS FORM IMMEDIATELY TO: HILARIE ASHTON  
BY FAX AT (212) 941-9407 OR EMAIL AT HASHTON@VERA.ORG