Generation ADA: Rise Up! 2015 Annual Conference on Independent Living (Image: red power fist outlined by a black circle)
Registration Form

1. Complete the form 
2. Save the form 
3. Email the form to Rie@ncil.org

2013 H Street NW, Sixth Floor 
Washington, D.C. 20006 
Fax: (202) 207-0341 

Prefix and Name: 
Title: 
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Fax: 
[  ] Check this box if you are a personal assistant to a registered attendee and are therefore not required to pay registration fees. I certify that I am providing personal assistance to: 

Full Conference Registration

Early Bird Rate (must be postmarked by April 29, 2015):
[  ] NCIL Member: $190
[  ] Youth Member: $110 (26 & Under)
[  ] NCIL Member: $310


Standard Registration (postmarked after April 29, 2015):
[  ] NCIL Member: $265
[  ] Youth Member: $110 (26 & Under)
[  ] Non-member: $385

Subtotal: $ 

[  ] I request a ticket to the ADA25 Celebration on Monday, July 27 (space limited to first 1000 Annual Conference registrants)
[  ] I plan to attend the Pre-Conference on Sunday, July 26 (free with full conference registration)

Daily Registration: Skip this section if you are registering for the full Conference
[  ] Sunday (Pre-Conference)
[  ] Monday
[  ] Wednesday
[  ] Thursday
[  ] Friday

[  ] NCIL Member: $115 / day
[  ] Non-member: $160 / day

Subtotal: $ 


Payment

Please charge my:

[  ] Visa
[  ] MasterCard
[  ] American Express
[  ] Discover
[  ] I'm sending a check
Total amount: $ 


Name on Card: 
Card #: 
Expiration: 
CID / CIV: 
If paying by credit card, consider mailing or faxing this form; email does not provide encrypted delivery of your personal information. 
Please make checks payable to National Council on Independent Living (Federal Tax ID: 74-2291620). 

Auxiliary Aids

Materials:

[  ] Standard Print
[  ] Large Print
[  ] Braille
[  ] Audio on CD
[  ] Text-Only

Diet:

[  ] Standard Fare
[  ] Vegetarian
[  ] Salt-Free
[  ] Low Colesterol
[  ] Other: 

Accommodations:

[  ] American Sign Language
[  ] Personal Assistant
[  ] Transcripts
[  ] Contact Sign
[  ] CART
[  ] Assistive Listening Device
[  ] Other: