Register A Personal Assistant - 2011 NCIL Annual Conference on Independent Living

Please Note: Personal Assistants are not required to pay the registration fee but should register below. Personal Assistants are welcome to attend all conference events, including scheduled meals and receptions.

* Required

Name of the Conference attendee being assisted: *

Name of Personal Assistant: *

PA Mailing Address (Line 1) *

PA Mailing Address (Line 2)

City *

State *

Zip code: *

Phone Number: *

Email: *

Materials: Please indicate whether you would like to receive publications in the following formats: *

Accommodations: Please indicate any accommodations you will need during Conference Hours: *

List any accommodations you need to participate that are not listed above:

Diet: *