ATIA 2022 Orlando Conference and Exhibition Pre-Conference Seminars: January 25-26, 2022 (Separate fee to participate) Conference & Exhibit Hall Open: Wednesday, January 26 – Saturday, January 29, 2022 Caribe Royale All Suites Hotel & Convention Center Orlando, Florida COVID-19 VACCINATION REQUIREMENT ATIA will be requiring all attendees who participate in the in-person ATIA 2022 Orlando event to be fully vaccinated.  From the beginning of this pandemic, ATIA has put all of this community’s health and safety first. This is what has helped to drive the current decision to require in-person attendees to be fully vaccinated and to show proof of this. We will not be offering any exceptions to this policy. If you are not vaccinated for any reason, we want to encourage you to attend our virtual event as a way to continue to be part of our AT community. Please answer the following required two questions before proceeding with the rest of the registration form: I am fully vaccinated or will be fully vaccinated by January 10, 2022, which is two weeks before the event begins. (Please select one answer.) ____Yes, I am vaccinated or will be vaccinated in time for the event. ____No, I am not vaccinated and not sure if I will be by the event. ____I will be attending the Virtual event only and do not require this Do you agree to show proof of vaccination during the registration check in? (Please select one answer.) ____I agree to show my vaccination card issued by the CDC or a photo of my official card, or other legal documentation that proves I have been fully vaccinated during registration check in at the event in Orlando. I understand that if I cannot provide proof of vaccination during check in I will not be given a badge and be asked to leave the event. No refunds will be provided. ____I will be attending the virtual event and will not need proof of vaccination. PRIVACY STATEMENT FOR ATIA 2022 IN-PERSON ATTENDEES ONLY By registering, you acknowledge the following privacy statement: The Assistive Technology Industry Association (the "Association") values your trust, and we understand the importance of protecting your privacy. We want to make sure you understand how your information is collected and used by the Association. This privacy statement describes what information we collect about you, including when and how we collect it; how we use it; with whom we may share it; and what choices you have regarding our use of your information. The Association will collect your name, title, organization, address, email, telephone number and other demographic questions related to your role and interests in AT. This information will be used for communications concerning the event and future marketing of Association programs and events. This information, excluding telephone numbers, will be included in a bar code located on your event badge. Exhibitors and the Association who scan your event badge will be able to use your information for promotional purposes. YOU HAVE THE RIGHT TO OPT OUT OF THIS PROMOTIONAL ACTIVITY BY NOT ALLOWING THE SCANNING OF YOUR BADGE. ATTENDEE REGISTRATION Please print clearly or type (this form may be copied for additional registrants.) First Name: __________________________________Last Name: ________________________________________ Badge Nickname: ________________________Position/Title: ____________________________________________ Company Name: ________________________________________________________________________________ Address: ______________________________________________________________________________________ City/State/Zip Code/Country: ______________________________________________________________________ Phone: ________________________ Fax: __________________________Email: ____________________________ ASSISSTANT REGISTRATION If you need to be accompanied by an assistant, please enter their name here for a complimentary assistant badge. Please note: assistant registrants are not eligible for continuing education credit. All assistants are also required to have received the COVID-19 vaccination. The below two questions are for the assistant. Assistant First and Last Name: ______________________________Assistant Email: __________________________ I am fully vaccinated or will be fully vaccinated by January 10, 2022, which is two weeks before the event begins. (Please select one answer.) ____Yes, I am vaccinated or will be vaccinated in time for the event. ____No, I am not vaccinated and not sure if I will be by the event. ____I will be attending the Virtual event only and do not require this Do you agree to show proof of vaccination during the registration check in? (Please select one answer.) ____I agree to show my vaccination card issued by the CDC or a photo of my official card, or other legal documentation that proves I have been fully vaccinated during registration check in at the event in Orlando. I understand that if I cannot provide proof of vaccination during check in I will not be given a badge and be asked to leave the event. No refunds will be provided. ____I will be attending the virtual event and will not need proof of vaccination. Virtual Event Marketing Opt Out: As part of the ATIA 2022 Virtual Event, ATIA will be sharing basic attendee data with our members companies who have sponsored activities. Please indicate if you would like to withhold your information from sharing with our members. We will be sharing the following data: Name, title, workplace, email, and interest areas. ____ I opt out of ATIA sharing my data If you have any special needs, accommodations, or dietary requests, please detail your requirements below: Please note: Requests for sign interpreters must be made one month in advance of the conference. Unfortunately, requests for sign interpreters after Friday, December 24, 2021, will not be accommodated. Sighted guides are available for one-hour periods onsite based on availability. Accessible conference materials will be available for download in advance of the conference. ______________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________ ATTENDEE PROFILE 1. Please indicate your attendee category (select all that apply): (A) Accessibility Professional (B) Advocate (C) AT Dealer (D) AT Specialist (E) Consultant (F) Consumer (G) Education Administrator (H) Federal Government (I) Hard of Hearing/Deaf Specialist (J) Higher Education (K) K-12 Educator (L) Occupational Therapist (M) Parent (N) Physical Therapist (O) Rehabilitation Counselor/Specialist (P) Speech-language Pathologist (Q) Special Education Director (R) Teacher of the Visually Impaired (S) Transition Coordinator (T) University Affiliate (U) Vision Specialist (V) 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. Have you previously attended an in-person ATIA Conference? (A) Yes (B) No If yes, please indicate the number of years you have attended an ATIA Conference: (A) 1 year (B) 2-5 years (C) More than 5 years (D) More than 10 years 4. Did you attend the 2021 ATIA Virtual Event? (A) Yes (B) No 5. Please indicate your interest area(s) (select all that apply): (A) AAC (Augmentative & Alternative Communication) (B) Accessibility (C) Blind/Low Vision (D) Deaf/Hard of Hearing (E) Education & Learning (F) Higher Education (G) Physical Access/Mobility (H) Transition/Workplace (I) Other (please specify) ___________________________________ 6. Are you interested in attending edcampAccess International at ATIA 2022? By selecting yes, your information will be shared with the organizers of the edcampAccess International unconference. (A) Yes (B) No 7. Do you have an ASHA membership number? If yes, please enter it here. Please note you must enter your ASHA membership number to obtain ASHA CEUs for approved courses. ________________________________________ Registration Categories / Fees Please identify the fees in the proper tier associated with your registration category and include the total below. Regular 10/1/21 – 12/3/21 Late 12/4/21 - Onsite In-Person Orlando Full Conference Registration In-Person Orlando Full Conference Registration: includes access to the Exhibit Hall, Wednesday Opening Reception and Educational Sessions. Pre-Conference Seminars require an additional registration fee. $580.00 $605.00 Group Registration 5+ Attendees (discount 5% per person based on attendee fee) $551.00 $574.75 Parent Registration: 30% Discount. (A letter describing your child’s disability must accompany your registration. A letter can be submitted with your registration form.) $406.00 $423.50 Student Registration: 30% Discount. (Proof of your full-time student status must accompany your registration. A letter can be submitted with your registration form.) $406.00 $423.50 Speaker Registration $385.00 $605.00 Exhibit Hall (Wednesday thru Saturday) $0.00 $0.00 In-Person Orlando + Virtual Event Bundle In-Person Orlando + Virtual Event Bundle: includes access to the Exhibit Hall, Wednesday Opening Reception and Educational Sessions. The virtual event bundle allows you to gain access to 80+ sessions post-event. Note that ALL CEU types are included with the Virtual Event Bundle for both the In-Person Event and Virtual Event. There is no need to purchase them separately. Pre-Conference Seminars require an additional registration fee. $729.00 $754.00 Group Registration 5+ (discount 10% per person based on attendee fee and virtual add-on fee) $656.10 $678.6 Virtual Event Registration Virtual Event Registration (Includes all CEUs; no additional payment necessary) $375.00 Parent Virtual Event Registration: 20% Discount (Includes all CEUs; no additional payment necessary. A letter describing your child’s disability must accompany your registration. A letter can be submitted with your registration form.) $300.00 Group Registration 5+ Attendees (discount 20% per person based on attendee fee) $300.00 Single Day Registration One Day (includes access to the Exhibit Hall and Education Sessions on the day you select Thursday or Friday), as well as a complimentary Saturday registration) $300.00 Please Choose: Thursday or Friday Add-Ons Pre-paid Lunch Ticket: Select Days required: Tuesday / Wednesday / Thursday / Friday $20.00 per lunch ticket In-Person Event CEU Admin Fee (Must be purchased in order to receive CEUs from any session. The fee covers all types of CEUs for the entire conference.) CEUs available: ACVREP, ASHA, AOTA, IACET, CRC Note that ALL CEU types are included with the In-Person Orlando + Virtual Event Bundle for both the In-Person Event and Virtual Event. You only need to purchase CEUs if you are only attending In-Person or if you decide to add the virtual event add-on after your initial registration. $30.00 Pre-Conference Seminar Information Pre-Conference Seminars are all-day workshops held on Tuesday, January 25, 2022 and Wednesday, January 26, 2022, presented by leading national and international AT professionals. There are separate fees to attend a Pre-Conference Seminar. Pre-Conferences are scheduled from 8:00 AM – 4:00 PM with an hour for lunch from 12:00 – 1:00 PM. Please note: If you want to earn CEUs for a Pre-Conference Seminar, CEUs for the ATIA 2022 Conference, inclusive of Pre-Conferences, are available for a $30 fee. This includes all CEU types. Two Day Pre-Conference Seminar (1/25/22 - 1/26/22) $ 555.00 One Day Pre-Conference Seminar (1/26/22) $ 330.00 Date/Time: Tuesday, January 25 & Wednesday, January 26, 8:00am – 4:00pm Session Type: Two day Session Code: PRE-2AAC2 Strand: Education & Learning: Early Intervention – 12/Higher Education Session Title: AT Bootcamp! Understanding and Implementing Assistive Technology Speaker: Brian Wojcik, Assistive Technology Partnership; Kelly Fonner, Kelly Fonner Consulting; Mike Cole, Use Your Words P.C.; Mike Marotta, Inclusive Technology Solutions, LLC Session Code: PRE-2AAC3 Strand: Augmentative and Alternative Communication (AAC) Session Title: PODD Communication Books Two Day Introductory Workshop Speaker: Linda Burkhart, Augmentative Communication and Assistive Technology Consultant/Specialist; *There is a $20 materials fee associated with this program. Fee covers the in-session supplies and should be paid to the speaker directly during the seminar. Session Code: PRE-2ATPAP1 Strand: Assistive Technology for Physical Access and Participation Session Title: Discover The Joy of AT Making - A 2 Day “Hands-On” Intensive AT Makers Workshop Speaker: Therese Willkomm, Director of ATinNH, University of New Hampshire *There is a $50 materials fee associated with this program. Fee covers the in-session supplies and should be paid to the speaker directly during the seminar. Session Code: PRE-2EDU1 Strand: Education & Learning: Early Intervention – 12/Higher Education Session Title: AT Capacity Building Workshop: Intentional changes to strengthen your AT Program Speaker: Gayl Bowser, M.S. Ed., Independent Consultant, Assistive Technology Collaborations; Aaron Marsters, Ph.D., CIV, OSD/DoDEA-Europe, Dr Session Code: PRE-2VHT1 Strand: Vision & Hearing Technologies Session Title: Practitioner’s Handbook: AT Services for People who are Blind or have Low Vision Speaker: Rachael Sessler Trinkowsky, Ph.D., CRC, CATIS, Technology Training & Vocational Coordinator and AT Program Coordinator, Lighthouse for the Blind of the Palm Beaches and UMass Boston; Stacy Kelly, Ed.D., Professor, Northern Illinois University; Sean Tikkun, PhD, Assistant Professor, Northern Illinois University Date/Time: Wednesday, January 26, 8:00am – 4:00pm Session Type: One day Session Code: PRE-2AAC1 Strand: Augmentative and Alternative Communication (AAC) Session Title: Designing and Delivering Empowering Experiences to Teach language Using AAC! Speaker: Christopher Bugaj, MA, CCC-SLP, Inclusive Educational Experience Designer, Loudoun County Public Schools; Rachel Madel, SLP/Owner, Rachel Madel Speech Therapy Inc. Session Code: PRE-1ATPAP1 Strand: Assistive Technology for Physical Access and Participation Session Title: The Highs and Lows of Accessing Participation through the Continuum of AT Speaker: Charlie Danger, OT/R, ATP, Clinical Specialist, Barnsley Hospital NHS Foundation Trust; Judith Schoonover, MEd, OTR/L, ATP, FAOTA, Retired and Independent Consultant, Adaptations and Tools for Participation LLC Session Code: PRE-1EDU1 Strand: Education & Learning: Early Intervention – 12/Higher Education Session Title: Big Apple Charges Ahead! Assessments, HIAT, & Building School-Based Capacity Speaker: Lindsey Huntley, MA-CCC-SLP, ATP, Speech Supervisor Center for Assistive Technology, NYCDOE Center for Assistive Technology; Colleen Warn, PT, ATP, Director of Center for Assistive Technology, New York City Department of Education; Maricris Formoso-Santos, PT, ATP, AT Supervisor, NYCDOE Center for Assistive Technology; Joseph Piazza, OTL-L, Assistive Technology Supervisor, New York City Department of Education Session Code: PRE-1EDU2 Strand: Education & Learning: Early Intervention – 12/Higher Education Session Title: Considering New Realities: Innovative Tech for Reading and Writing Speaker: Mike Marotta, Inclusive Technology Evangelist, Inclusive Technology Solutions, LLC; Karen Janowski, MS Ed, EdTech Solutions 5 WAYS TO REGISTER ONLINE: www.atia.org/atia2022-registration FAX: 847-277-7414 EMAIL: registration@atia.org TELEPHONE: 847-620-4471 MAIL: ATIA Registration, 8324 Solutions Center, Chicago, IL 60677-8003 PAYMENT INFORMATION: Full payment must accompany registrations. ATIA Federal ID#: 77-0482095 Check (payable to ATIA) MC Visa AMEX Purchase Order (Original PO must accompany registration) Total Fees Due: $ _______________________________ Discount Code (if applicable): _________________ Check/Card/PO# ________________________________ Exp Date ____________CVV Code ___________ Name on card (please print) ________________________________________________________________ Signature: _______________________________________________________________________________ PURCHASE ORDER BILLING INFORMATION If you are paying with a purchase order, please provide billing contact information. Billing Contact Name: _______________________________________________ Billing Contact Phone Number: ________________________________________ Billing Contact Email Address: ________________________________________ If you submit this form via fax, email, online, or mail, you are agreeing to the applicable policies outlined below. Cancellation Policy: A full refund will be granted to cancellations made in writing on or before Friday, October 29, 2021. Name changes and substitutions are allowed at no fee. Regrettably, no refunds will be given on cancellations received on or after Saturday, October 30, 2021. Phone cancellations will not be accepted. Written cancellations must be sent by email to registration@atia.org or faxed to +1 847-277-7414.  If for any reason beyond ATIA’s control ATIA determines that the in-person portion of the ATIA 2022 Conference must be cancelled, and the virtual portion of the ATIA 2022 Conference is still held, Attendee understands and agrees that ATIA shall refund the difference between their current in-person registration fee and the full Virtual Event fee.  Attendee understands that their registration type shall be changed to a virtual attendee. Except for the partial refund, Attendee understands that they may lose all monies they have otherwise incurred for ATIA 2022, including travel, lodging, etc.  Purchase Order Payment Policy: If your organization is required to submit a purchase order for payment, please send your purchase order document with all pages of the registration form. Registrations paid by purchase order are subject to the Cancellation Policy. Purchase order payments are due no later than 30 days after the completion of the conference, by Monday, February 28, 2022. Payments received after February 28, 2022, will incur a $75 late payment fee.    Pre-Conference Seminar Transfer Policy: If you wish to switch to a different Pre-Conference Seminar, please contact registration@atia.org with details of the change by Friday, December 19, 2021. Regrettably transfer requests received after this date will not be processed. Requests to transfer to a different session onsite will not be honored.  Please Note: I understand that by registering and participating in ATIA and its events, activities, programs and other functions, I agree that ATIA shall not be held responsible for any claims, demands, actions, judgments, costs, and expenses, including costs of defense thereof, incurred by me, my employees, guests or clients, which arise due to any products and/or services delivered or otherwise provided to me, my employees, guests or clients. ATIA may use personal identifiable information collected, such as to help minimize any potential hotel attrition penalties for the association and by registering for the conference you consent to such use. If you have any questions or concerns please contact ATIA at registration@atia.org. On occasion, an ATIA photographer may take photos of participants at ATIA 2022 participating in conference functions or activities. Please be aware that these photos are for ATIA's use only, and may appear in ATIA conference programs, brochures, newsletters, website and other publications and materials. Your attendance constitutes your permission and consent for this photography and subsequent usage. ATIA 2022 Orlando Attendee Registration Form | Page 2