Logo - Solidarity - Everybody In - Annual Conference on Independent Living 2016 Complete, save, and send this form to NCIL: Email: rie@ncil.org Mail: 2013 H Street NW / Sixth Floor Washington, D.C. 20006 Fax: (202) 207-0341 Instructions: 1. Complete the form 2. Save the form 3. Email the form to Rie@ncil.org Prefix and Name: Title: Organization: Address: City, State, Zip: Email: Phone: 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: Heading: Full Conference Registration Early Bird Rate (must be postmarked by April 29, 2016): [ ] NCIL Member: $190 [ ] Youth Member: $110 (26 & Under) [ ] Non-member: $310 Standard Registration (postmarked after April 29, 2016): [ ] NCIL Member: $265 [ ] Youth Member: $110 (26 & Under) [ ] Non-member: $385 Subtotal: $ [ ] I plan to attend the Pre-Conference on Sunday, July 24 (free with full conference registration) Heading: Daily Registration: Skip this section if you are registering for the full Conference [ ] Sunday (Pre-Conference) [ ] Monday [ ] Wednesday [ ] Thursday [ ] NCIL Member: $115 / day [ ] Non-member: $160 / day Subtotal: $ Heading: 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). Heading: Auxiliary Aids Materials: [ ] Standard Print [ ] Large Print [ ] Braille [ ] Audio on USB [ ] Plain Text [ ] Braille Program + Other Materials in Plain Text Diet: [ ] Standard Fare [ ] Vegetarian [ ] Salt-Free [ ] Low Cholesterol [ ] Other: Accommodations: [ ] American Sign Language [ ] Personal Assistant [ ] Transcripts [ ] Contact Sign [ ] CART [ ] Other: [ ] Assistive Listening Device