Sample 
Participant 
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 
___________________________________________________________ 



ARRIVAL 
AND 
DEPARTURE 
INFORMATION 


You 
are 
responsible 
for 
arranging 
your 
own 
airline 
and 
hotel 
reservations. 
However, 
as 
part 
of 
our 
internal 
planning 
process, 
we 
would 
greatly 
appreciate 
if 
you 
can 
let 
us 
know 
the 
below 
information 
(if 
known): 


6. 
Please 
indicate 
your 
expected 
day 
and 
time 
of 
arrival 
and 
departure. 
Arrival 
Date 
and 
Time 
______________________________________________ 
Departure 
Date 
and 
Time 
___________________________________________ 
7. 
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 
____ 
8. 
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 
____________________________________________ 



OTHER 


9. 
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.