ATIA 2010 Chicago Conference and Exhibition
OCTOBER 27 – 30, 2010
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:  ____________________________________________________________________________________


If you received an offer code from ATIA or a VIP code from an exhibitor, enter it here:  _______________

					Early		Regular			Late
				Until 8/20/2010	        8/21/2010 – 10/1/2010	 	After 10/1/2010
				
Attendee Registration			$425			$475		$525
Group Registration 5+			$400			$450		$500
Group Registration 10+			$390			$440		$490
Speaker Registration			$350			$350		$400
Speaker Registration (Orlando & Chicago)	$630			$630		$720
*Parent/Student Registration			$200			$200		$200

Attendee Pre-Conference Seminar		$275	Add Pre-Con code**:_______    	___Wed. $12 Lunch

Parent/Student Pre-Conference Seminar	$137.50	Add Pre-Con code**:_______    	___Wed. $12 Lunch

**See www.atia.org/preconference for Pre-Conference session codes.		
	
					Thursday		Friday		Saturday
				
Attendee Registration			$300		$300		$150
Parent/Student Registration			$150		$150		$75
Lunch					$12		$12		N/A



TOTAL  $ ____________

*Must provide documentation

___ 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. 

3  WAYS  TO  REGISTER


ONLINE:  www.atia.org 	FAX: 847-277-7414 	MAIL:  	ATIA Registration
							1325 Paysphere Circle
							Chicago, IL 60674


PAYMENT  INFORMATION:  Full payment must accompany registrations.


Check (payable to ATIA)		MC	Visa	AMEX	PO

Total Fees Due: $ __________________________________________________________________________

Check/Card/PO# _________________________________________ Exp Date ________________________

Name on card (please print)  ________________________________________________________________

Signature:  ________________________________________________________________________________


ATTENDEE  PROFILE

1. Please indicate your attendee category (check all that apply): 

(A) Education administrator 

(B) Consultant 

(C) Government 

(D) Occupational therapist 

(E) Rehabilitation specialist 

(F) Physical therapist 

(G) Special education director 

(H) Speech-language pathologist 

(I) AT specialist 

(J) K-12 educator 

(K) University affiliate 

(L) Corporate 

(M) Vision specialist

(N) Hard of hearing/Deaf specialist 

(O) Consumer 

(P) Advocate 

(Q) Parent 

(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 Chicago/ATIA 2010 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. Please select conference materials in any of these alternate 
formats (For persons with disabilities only – must be requested by August 20):

(A) Braille    

(B) Large print   

(C) Tactile map   

(D) Daisy Books

(E) (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) Transition/Vocational 

(G) Other (please specify)  ___________________________________