2018 Annual Conference on Independent Living Registration Form

Complete, save, and send this form to NCIL.
Email: sylena@ncil.org 
Mail: 2013 H Street NW / Sixth Floor Washington, D.C. 20006 
Fax: (202) 207-0341

Full Conference Registration: All rates are listed per person. The member organizations rate is available to all staff, board, and consumers of all 2018 NCIL member organizations. To claim the member organization rate, you must list an organization in your contact information so we can verify your membership.

[  ] 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: 

Early Bird Rate (must be postmarked by April 27, 2018):

[  ] NCIL Member Organization: $190
[  ] NCIL Individual Member: $260
[  ] Youth Member: $110 (26 & Under)
[  ] Non-member: $310

Standard Registration (postmarked after April 27, 2018):

[  ] NCIL Member Organization: $265
[  ] NCIL Individual Member: $335
[  ] Youth Member: $110 (26 & Under)
[  ] Non-member: $385

Subtotal: $

Daily Registration: Skip this section if you are registering for the full Conference.

[  ] Wednesday, July 25
[  ] Monday, July 23
[  ] Thursday, July 26

Price: 
- Non-member: $160 / day
- NCIL Member: $115 / day

Subtotal: $

Registrant Information

Organization: 
Prefix and Name: 
Title: 
Street Address: 
City: 
State: 
Zip: 
Email: 
Phone: 
Fax: 

Materials:

[  ] Standard Print
[  ] Electronic Materials: PDF, Word, and plain text on USB
[  ] Braille Program + other materials in Plain Text on USB
[  ] Braille
[  ] Audio on USB
[  ] Large Print

Diet:

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

Auxiliary Aids: 

[  ] Transcripts
[  ] CART
[  ] American Sign Language

Accommodations:

[  ] Assistive Listening Device
[  ] Personal Assistant
[  ] Contact Sign
Other: 

Payment

Please charge my:
[  ] MasterCard
[  ] American Express
[  ] Discover
[  ] Visa
[  ] 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).