ATIA 2009 Chicago Conference And Exhibition OCTOBER 28 – 31, 2009 • Renaissance Schaumburg Hotel & Convention Center • Schaumburg (Chicago), IL ATIA REGISTRATION FORM Please print clearly or type (this form may be copied for additional registrants). First Name: _________________________________________ Last Name: _________________________________________ Position/Title Organization:_________________________________________________________________________________ Preferred Mailing Address: _________________________________________________________________________________ City/State/Prov/Zip Code/Country: ___________________________________________________________________________ Phone: ___________________________Fax:___________________________ E-mail:_________________________________  Check here if you do NOT want to receive e-mails from ATIA Exhibitors and Members with details including special offers or other conference-related materials. Conference Registration By July 17 July 18 Sept 19 Oct 17 - _ _ Sept 18 Oct 16 Onsite  Standard Registration $395 $450 $485 $525  Speaker Registration $350 $400 $400 $400  Parent Registration $200 $200 $200 $200 (A letter describing your child’s disability must accompany faxed or mailed registration.)  Student Registration $200 $200 $200 $200 (Proof of full-time status must accompany faxed or mailed registration.) $ _________ One Day Registration (If you plan to attend more than one day,standard registration rates apply.) Parent/Student July 17 July 18- Sept 19- Oct 17- Sept 18 Oct 16 Onsite  Thursday, October 29, 2009 $100 $250 $250 $300 $300  Friday, October 30, 2009 $100 $250 $250 $300 $300  Saturday, October 31, 2009 $50 $125 $125 $175 $175 $ _________ Discounts  Group Discount 5+ Attendees Pre-paid per person $350 $350 NA NA Total group registration payment must be pre-paid. ORDER # __________  Alliance Partner Discount CODE # ________ $350 $350 $400 $400  ATIA VIP Attendee Discount CODE # _________ $350 NA NA NA $ _________ Pre-Conference Seminars Wednesday, October 28, 2009, 8:00 am – 4:00 pm. Only one Pre-Conference Seminar may be selected. By Pre-Conference Seminars - Wednesday, October 28, 2009, 8:00 am – 4:00 pm. Only one Pre-Conference Seminar may be selected. Seminar fee includes course materials. Additional onsite materials fee may apply – check Web site for details. By: Sept 19- Parent/ Sept 18 Onsite Student  PRE-AAC100 Implementation of AAC Systems into Work, School and Lives of those with Complex Communication Needs $ 275 $ 300 $125  PRE-AAC200 Weaving the Threads of Communication $ 275 $ 300 $125  PRE-AS100 Creating Low Cost Assistive Technology Solutions In Minutes $ 275 $ 300 $125  PRE-AS200 Integrating Web 2.0 Tools and AT: Interventions for the 21st Century $ 275 $ 300 $125  PRE-AS300 Overview of Assistive Technology $ 275 $ 300 $125  PRE-EL100 RTI, UDL and Differentiated Instruction $ 275 $ 300 $125 and the Role of Technology Supports  PRE-EL200Include All Learners in a Technology-Facilitated $ 275 $ 300 $125 Differentiated Curriculum  PRE-RPD100 Designing, Implementing, and Evaluating $ 275 $ 300 $125 Universal Design for Learning Interventions  PRE-S100 Technology for People Who Are Blind or Visually Impaired $ 275 $ 300 $125 $ _________ Optional Pre-Paid Lunch Ticket – lunch includes entree, side and drink. Note: Cash purchase food concession stands will be open during the conference.  $12 Wednesday lunch  $12 Thursday lunch  $12 Friday lunch $ _________ $ _________ Total Amount First Name: ______________________________________ Last Name: __________________________________________ Attendee Profile 1. Please indicate your attendee category (check all that apply): (A)  Education administrator (G)  Special education director (M)  Vision specialist (B)  Consultant (H)  Speech-language pathologist (N)  Hard of hearing/Deaf specialist (C)  Federal government (I)  AT specialist (O)  Consumer (D)  Occupational therapist (J)  K-12 educator (P)  Advocate (E)  Rehabilitation specialist (K)  University affiliate (Q)  Parent (F)  Physical therapist (L)  Corporate (R)  Other (please specify) _____________ 2. Please indicate what most closely describes your role in purchasing decisions in your organization: (A)  I am the purchasing decision-maker (B)  I approve purchases (C)  I recommend/influence purchasing decisions (D)  I am not involved in purchasing decisions 3. How did you hear about this conference? (A)  Direct mail brochure (B)  Word-of-mouth (C)  AT Vendor (please specify) ______________ (D)  ATIA Web site (E)  E-mail (F)  Conferences ( CSUN,  CTG,  Other (please specify) ____________ (G)  Other (please specify) _____________________ 4. What other AT conferences have you attended over the past year? (check all that apply): (A)  ATIA 2009 Orlando (B)  Closing-The-Gap (C)  CSUN (California State University Center on Disabilities) (D)  ASHA (American Speech-Language-Hearing Association) (E) RESNA (Rehabilitation Engineering & Assistive Technology Society of North America) (F)  AOTA (American Occupational Therapy Association) (G)  CEC (Council for Exceptional Children) (H)  Other (please specify) _________________________________ (I)  None 5. If you require special assistance during the conference, please indicate so below. An ATIA representative will contact you via e-mail approximately one month prior to the conference. All conference proceedings are provided electronically on a CD-ROM/DVD. (Check all that apply): (A)  Braille (B)  Large print (C)  Tactile map (D)  Other (please specify) ___________________ 6. Have you previously attended an ATIA Conference?  Yes  No 7. Please indicate your interest area/s (check all that apply): (A)  AAC (Augmentative & Alternative Communication) (B)  Blind/Low Vision (C)  Deaf/Hard of hearing (D)  Education/Learning (E)  Physical Access/Mobility (F)  Other (please specify) _______________________ Payment Options Online – You may register quickly and conveniently at www.atia.org. Simply fill out the online form and submit your credit card number (credit cards required for online registration). Check – All registrations paid by check must be mailed or brought on site. Make all checks payable to ATIA and mail to: ATIA Registration, 1325 Paysphere Circle, Chicago, IL 60674. Checks must be postmarked by October 9, 2009. Purchase Order/PO – Federal ID #77-0482095. The Purchase Order should be made payable to: ATIA Registration, 1325 Paysphere Circle, Chicago, IL 60674. If paying by PO, please include contact’s name, e-mail and phone number. PO bookings must be made by October 9, 2009. Credit Card – Visa, MasterCard and American Express only. All registrations paid by credit card may be mailed or faxed or submitted online at www.atia.org. Confirmations – For all registrations mailed in and postmarked by October 9, 2009 confirmation will be sent by e-mail. Payment Information Full payment must accompany registrations  Check (payable to ATIA)  MasterCard  Visa  American Express Total Fees Due: $ __________________ Credit Card # ____________________________________ Exp Date _________ Name on card (please print) __________________________________________ Signature: _______________________________________________________ Cancellation Policy: A full refund will be granted to cancellations made in writing on or before September 18, 2009. To cover administrative costs, a service fee of $100 will be charged for all cancellations received from Saturday, September 19, 2009 through Wednesday, September 30, 2009. Regrettably, no refunds will be given on cancellations received after Thursday, October 1, 2009. Phone cancellations will not be accepted. Written cancellations must be sent by e-mail to registration@atia.org, faxed to +1 312.673.6939 or mailed to ATIA Registration: 1325 Paysphere Circle, Chicago, IL 60674.