Attendee Registration

Early Bird Registrations until May 22, 2019:

Preconference AT Maker Event (Sunday Only) - $150 includes $25 materials fee, Breakfast & Lunch
Regular Conference (Monday & Tuesday Only) - $250 – includes Breakfasts & Lunches
Preconference & Regular Conference; (Sunday, Monday & Tuesday) - $375 includes $25 materials fee, Breakfasts & Lunches
AIVRTTAC Meeting (Sunday Only) - $0 – No meals provided
AIVRTTAC Meeting & Regular Conference (Sunday, Monday & Tuesday) - $250 - includes Breakfasts & Lunches on Monday & Tuesday only

Regular Registration after May 22, 2019:

Preconference AT Maker Event (Sunday Only) - $225 includes $25 materials fee, Breakfast & Lunch
Regular Conference (Monday & Tuesday Only) - $325 – includes Breakfasts & Lunches
Preconference & Regular Conference; (Sunday, Monday & Tuesday) - $450 includes $25 materials fee, Breakfasts & Lunches
AIVRTTAC Meeting (Sunday Only) - $0 – No meals provided
AIVRTTAC Meeting & Regular Conference (Sunday, Monday & Tuesday) - $325 - includes Breakfasts & Lunches on Monday & Tuesday only

Submitter's Name *

First Last

Submitter's Email *

Enter Email Confirm Email

Submitter's Cell Phone *

If you don't have a cell phone please enter the best phone # to reach you during business hours in the summer.

How many do you want to register? (You may register up to 3 people at a time.)

Attendee #1

Name *

First Last

Company

Position/Title

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone *

If you don't have a cell phone please enter the best phone # to reach you during business hours in the summer.

Email *

Enter Email Confirm Email

Participant Category *

Participant Category Explain *

If Administrator or Other - specify

Employment Setting *

If Other - specify *

Reasonable Accommodations

In order to guarantee a reasonable accommodation, the request must be received by June 28, 2019.

ASL Interpreter
Assisted Listening Device
Braille
CART
Electronic access to print
Large Print
Other

If Other - specify *

For Conference Planning Purposes, please check if you

Will have a service animal with you
Will use manual or powered mobility at the conference

Select a primary focus area track *

You can attend any conference session even if it is not in your primary focus area.

American Indian Vocational Rehabilitation Training (AIVRTTAC)
Assistive Technology (AT)
Evidence Base Practice in Disability Disciplines (EBP)

Select a Registration Option: *

Preconference AT Maker Event (Sunday Only)
Regular Conference (Monday & Tuesday Only)
Preconference & Regular Conference; (Sunday, Monday & Tuesday)
AIVRTTAC Meeting (Sunday Only)
AIVRTTAC Meeting & Regular Conference (Sunday, Monday & Tuesday)

Discount Code

Your discount (if any) will auto calculate after your discount code is entered. In order to qualify for the "schools" discount, you must be an active employee or contractor working for an AZ public school district or AZ charter school.

Discount of $250 (if applicable)

Price: $0.00

Discount of $100 (if applicable)

Price: $0.00

Discount of $150 (if applicable)

Price: $0.00

Discount of $375 (if applicable)

Price: $0.00

Name of School District/Charter School *

Supervisor’s Name *

Supervisor's Email *

Supervisor's Phone *

Note: Discount is contingent upon NAU’s verification of above information.

Attendee #2

Name *

First Last

Company

Position/Title

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone *

If you don't have a cell phone please enter the best phone # to reach you during business hours in the summer.

Email *

Enter Email Confirm Email

Participant Category *

Participant Category Explain *

If Administrator or Other - specify

Employment Setting *

If Other - specify *

Reasonable Accommodations

In order to guarantee a reasonable accommodation, the request must be received by June 28, 2019.

ASL Interpreter
Assisted Listening Device
Braille
CART
Electronic access to print
Large Print
Other

If Other - specify *

For Conference Planning Purposes, please check if you

Will have a service animal with you
Will use manual or powered mobility at the conference

Select a primary focus area track *

You can attend any conference session even if it is not in your primary focus area.

American Indian Vocational Rehabilitation Training (AIVRTTAC)
Assistive Technology (AT)
Evidence Base Practice in Disability Disciplines (EBP)

Select a Registration Option: *

Preconference AT Maker Event (Sunday Only)
Regular Conference (Monday & Tuesday Only)
Preconference & Regular Conference; (Sunday, Monday & Tuesday)
AIVRTTAC Meeting (Sunday Only)
AIVRTTAC Meeting & Regular Conference (Sunday, Monday & Tuesday)

Discount Code

Your discount (if any) will auto calculate after your discount code is entered. In order to qualify for the "schools" discount, you must be an active employee or contractor working for an AZ public school district or AZ charter school.

Discount of $250 (if applicable)

Price: $0.00

Discount of $100 (if applicable)

Price: $0.00

Discount of $150 (if applicable)

Price: $0.00

Discount of $375 (if applicable)

Price: $0.00

Use Save Values As Attendee #1

Name of School District/Charter School *

Supervisor’s Name *

Supervisor's Email *

Supervisor's Phone *

Note: Discount is contingent upon NAU’s verification of above information.

Attendee #3

Name *

First Last

Company

Position/Title

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone *

If you don't have a cell phone please enter the best phone # to reach you during business hours in the summer.

Email *

Enter Email Confirm Email

Participant Category *

Participant Category Explain *

If Administrator or Other - specify

Employment Setting *

If Other - specify *

Reasonable Accommodations

In order to guarantee a reasonable accommodation, the request must be received by June 28, 2019.

ASL Interpreter
Assisted Listening Device
Braille
CART
Electronic access to print
Large Print
Other

If Other - specify *

For Conference Planning Purposes, please check if you

Will have a service animal with you
Will use manual or powered mobility at the conference

Select a primary focus area track *

You can attend any conference session even if it is not in your primary focus area.

American Indian Vocational Rehabilitation Training (AIVRTTAC)
Assistive Technology (AT)
Evidence Base Practice in Disability Disciplines (EBP)

Select a Registration Option: *

Preconference AT Maker Event (Sunday Only)
Regular Conference (Monday & Tuesday Only)
Preconference & Regular Conference; (Sunday, Monday & Tuesday)
AIVRTTAC Meeting (Sunday Only)
AIVRTTAC Meeting & Regular Conference (Sunday, Monday & Tuesday)

Discount Code

Your discount (if any) will auto calculate after your discount code is entered. In order to qualify for the "schools" discount, you must be an active employee or contractor working for an AZ public school district or AZ charter school.

Discount of $250 (if applicable)

Price: $0.00

Discount of $100 (if applicable)

Price: $0.00

Discount of $150 (if applicable)

Price: $0.00

Discount of $375 (if applicable)

Price: $0.00

Use Save Values As Attendee #1

Name of School District/Charter School *

Supervisor’s Name *

Supervisor's Email *

Supervisor's Phone *

Note: Discount is contingent upon NAU’s verification of above information.

Registration Total

TOTAL

$0.00

Payment Options *

by credit card online
by PO
by PO Pending
by Check

Payment Options *

N/A, my order total is $0

If paying by PO *

PO Number	Amount

If paying by check *

Check Number	Amount

PO Pending Amount *

Need Help?
For Registration or payment questions, contact Martha Lewis at 602.776.4670, 800.477.9921 martha.lewis@nau.edu

Refunds:
Refunds - minus a $25 processing fee per attendee - will only be given if a written cancellation notice is received via email, mail, or fax by June 8, 2019.

Release for Use of Photographs
By registering as an attendee of the 2019 Evidence for Success Conference, you grant NAU/IHD/AzTAP the right and permission to use, publish and republish photographs or images in which you are included in whole or part in printed or electronic media.

Register Date