Attendee Registration

Early Bird Registrations until January 18, 2019: $125
Regular Registration after January 18, 2019: $150
Registration Deadline March 15, 2019

For student discount pricing contact 860-424-4881

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.

How many do you want to register?

Attendee #1

Same as Submitter

Name *

First Last

Organizaton/School

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.

Email *

Enter Email Confirm Email

Please indicate which category best describes you *

Representative of Education (Administrator, AT Specialist, General or Special Educator, Transition Specialist, University Affiliate, Related Service Providers)
Representative of Employment (VR Counselor, Community Rehab Provider)
Representative of Allied (Physical Therapist, Occupational Therapist, Speech Language Pathologist, Hard-of-hearing/Deaf Specialist, Blind/Low Vision Specialist) Health and Rehabilitation
Representative of Community Living
Representative of Technology
AT User
Family Member or Friend of an AT User

Reasonable Accommodations

ASL Interpreter
Braille
CART
Large Print
Other

If Other - specify *

For Conference Planning Purposes, please check if you

Will bring a service animal
Use/bring a manual w/c
Use/bring a power w/c or scooter
Will bring a Personal Care Assistant

Name of Personal Care Assistant *

Any Food Allergies? *

Yes
No

If yes, please describe *

Register Attendee #1: *

Full Conference

Attendee #2

Name *

First Last

Organizaton/School

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.

Email *

Enter Email Confirm Email

Please indicate which category best describes you *

Representative of Education (Administrator, AT Specialist, General or Special Educator, Transition Specialist, University Affiliate, Related Service Providers)
Representative of Employment (VR Counselor, Community Rehab Provider)
Representative of Allied (Physical Therapist, Occupational Therapist, Speech Language Pathologist, Hard-of-hearing/Deaf Specialist, Blind/Low Vision Specialist) Health and Rehabilitation
Representative of Community Living
Representative of Technology
AT User
Family Member or Friend of an AT User
Other Other

Reasonable Accommodations

ASL Interpreter
Braille
CART
Large Print
Other

If Other - specify *

For Conference Planning Purposes, please check if you

Will bring a service animal
Use/bring a manual w/c
Use/bring a power w/c or scooter
Will bring a Personal Care Assistant

Name of Personal Care Assistant *

Any Food Allergies? *

Yes
No

If yes, please describe *

Register Attendee #2: *

Full Conference

Attendee #3

Name *

First Last

Organizaton/School

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.

Email *

Enter Email Confirm Email

Please indicate which category best describes you *

Representative of Education (Administrator, AT Specialist, General or Special Educator, Transition Specialist, University Affiliate, Related Service Providers)
Representative of Employment (VR Counselor, Community Rehab Provider)
Representative of Allied (Physical Therapist, Occupational Therapist, Speech Language Pathologist, Hard-of-hearing/Deaf Specialist, Blind/Low Vision Specialist) Health and Rehabilitation
Representative of Community Living
Representative of Technology
AT User
Family Member or Friend of an AT User
Other Other

Reasonable Accommodations

ASL Interpreter
Braille
CART
Large Print
Other

If Other - specify *

For Conference Planning Purposes, please check if you

Will bring a service animal
Use/bring a manual w/c
Use/bring a power w/c or scooter
Will bring a Personal Care Assistant

Name of Personal Care Assistant *

Any Food Allergies? *

Yes
No

If yes, please describe *

Register Attendee #3: *

Full Conference

Registration Total

Coupon Code

TOTAL

$0.00

Payment Options *

Your registration is NOT complete until we receive payment.

by Credit Card
by PO
by Check

Payment Options *

N/A, my order total is $0

If paying by PO *

Mail to: DORS Business Office, 55 Farmington Avenue, 12th Floor, Harford, CT 06105

PO Number	Amount

If paying by check *

Make payable to: Treasurer of the State of CT Mail to: DORS Business Office, 55 Farmington Avenue, 12th Floor, Harford, CT 06105

Check Number	Amount

Need Help?
For Registration or payment questions, contact the DORS Business office at 860-424-4921 or by email conference@cttechact.com

Refunds:
Refunds - minus a $25 processing fee - will only be given if a written cancellation notice is received via email, or mail, by March 1, 2019.

Release for Use of Photographs
By registering as an attendee of Connecticut’s Achievement Through Technology Conference, you grant the Connecticut Tech Act Project 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.

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