Sample Presenter/Associate Registration Form INSERT MEETING TITLE INSERT DATE INSERT LOCATION REGISTRATION DUE DATE: MONTH DAY(XX), YEAR(XXXX) Please do your best to answer all questions as completely as possible to assist the Vera staff in the planning process. We look forward to meeting with you in (INSERT MONTH)!! CONTACT INFORMATION 1. Please fill in your contact information. First Name _______________________________________________________ Last Name________________________________________________________ Agency ________________________________________________________ Title ________________________________________________________ Address ________________________________________________________ City ________________________________________________________ State ________________________________________________________ Zip Code ________________________________________________________ Phone ________________________________________________________ TTY ________________________________________________________ Fax ________________________________________________________ Email ________________________________________________________ 2. Contact Information appears in our meeting materials, including the program. Can we share your contact information with other grant recipients/meeting attendees? Yes _____ No _____ 3. Emergency Contact Person and Information 4. Are you traveling with a Personal Care Attendant (PCA) or Personal Assistant (PA)? **if yes, please complete a separate registration form for him or her.** Yes ____ No ____ MEETING ACCESSIBILITY INFORMATION 5. We value access and safety and strive to make our meetings accessible and welcoming to all participants. Using the principles of universal design, we plan all aspects of our meetings with the widest range of potential participants and circumstances in mind. For example, we have selected a hotel with a commitment to access; meeting rooms and areas are set to allow for maximum space and access; all presenters have been provided with guidance on making their presentations accessible; and all meeting materials are provided in 14 point font. We also provide accommodations to meet the individual needs of participants at our meetings. Please select any accessibility accommodation(s) you require for the meeting below. If your accommodation(s) is not listed, please request it by using the “other” category. Please be as specific as possible. None required _____ ASL Interpreter ____ Electronic copies of meeting materials in advance ____ Electronic text file of meeting materials (to be available at the meeting) _____ Materials in Braille _____ Materials in font over 14pt _____ Wheelchair access _____ Other ___________________________________________________________ MEETING AUDIO/VISUAL(A/V) REQUESTS 6. Please let us know if you have any specific requests for your session. Please select all requests below: Projector for PowerPoint Presentation _____ Flipchart and Markers _____ DVD Player _____ Other ___________________________________________________________ 7. Will you be bring your own laptop (for instance, for PowerPoint Presentations)? Yes (if so, indicate Mac or PC) ______________ No ____ ARRIVAL AND DEPARTURE INFORMATION If you are going to be traveling for this meeting, please note that you are responsible for arranging your own airline reservations with our travel agent: Daranee Perfecto, JTB, Email: dperfecto@jtbusa.com or Voice: (201) 288-8913. Please answer the below information (if known): 8. Please indicate your expected day and time of arrival and departure. Arrival Date and Time ______________________________________________ Departure Date and Time ___________________________________________ 9. Will you be requesting a(n): No lodging required ____ ADA Room with Roll In Shower ____ ADA Room with Tub and Chair ____ Chemical Free Room ____ Room Accessible for Deaf/Hard-of-Hearing ____ None of the above ____ 10.ADDITIONAL LODGING PREFERENCES Please note these are not guaranteed. None required ____ Early Check-In _____ Late Check-In _____ Late Check-Out _____ King Bed _____ Double Beds _____ Other ___________________________________________________________ DIETARY INFORMATION 11.Continental breakfast will be provided on X day(s) of the meeting and lunch will be provided on X day(s). To ensure that meals meet your dietary needs, please mark your selection(s) below: No dietary needs ____ Pre-Cut ____ Vegan _____ Vegetarian _____ Gluten-Free ____ Other, including allergies ____________________________________________ 12.Please tell us of any additional needs you may have for this meeting. Please be as specific as possible. We may contact you for further information if necessary. Every effort will be made to accommodate advance requests; on-site requests cannot be guaranteed. Reasonable accommodations will be provided during meeting sessions and meals (excluding meals on your own). Referrals for assistance outside of the meeting can be made available. Please contact Emily Dunn at edunn@vera.org with any questions.