Family Café: 2010 Conference Registration

June 18-20, 2010 * Disney Coronado Springs Resort * Orlando, Florida

Step 1 of 2. To register you must complete both Steps 1 and 2

* Required fields.

I am a* :

Parent (No Registration Fee)

Professional/Provider ($100 Registration Fee)
Caregiver (No Registration Fee)

Person with a Disability (No Registration Fee)
Other Family Member (No Registration Fee)

First Name *:

Last Name *:

Address *:

City *:

State *:

Zip *:

County *:

Daytime Phone :

Fax :

Email *:

Other Family Members Attending (please list the names of all persons attending with you as you would like them to appear on their conference badges)**:

1. First : Last :	2. First : Last :
3. First : Last :	4. First : Last :
5. First : Last :	6. First : Last :

**If you receive Financial Assistance, these individuals will be assigned to your hotel room. No additions or changes may be made after this registration has been submitted.

I will require: Language Interpreter ( language : )

American Sign Language Services

Large Print materials

Braille materials

Other ( specify : )

Payment:

FOR PROFESSIONALS ONLY. A PayPal link will be provided on submission of the application form. There is no registration fee for individuals with disabilities or their family members.

Cancellation Policy:

We are sorry, but there will be no refunds issued for cancellations. Substitutions are permitted. Remember, registration fees do NOT cover hotel costs. If you have questions about the payment procedure or the conference in general, call the Family Café office at 888-309-2233 (CAFÉ).

I or a member of my family am/are currently on a waiting list for services from a State Agency: Yes No

I/ my child(ren) receive services through (please check all that apply): Agency for Persons with Disabilities

Exceptional Student Education (ESE)
Childrens Medical Services

Medicaid

Childrens Mental Health
Early Steps Program

Brain & Spinal Cord Injury Program
Department of Education, Division of Blind Services

Vocational Rehab (current)

Vocational Rehab (past)l
CDC+ Waiver

Other ( please describe : )

I am willing to volunteer for: Registration Desk

Room Monitor

Conference Bag Stuffing
Language Interpreter ( language : )

Financial Assistance Guidelines

In order to qualify, you must be a person with a disability or their family member residing in Florida, and you must live more than 50 miles from the City of Orlando. Funding will be distributed according to State of Florida guidelines. Applicants will be notified of their status by mail in April, 2009. NOTE: All Assistance is based on the availability of funding.

I would like to request Financial Assitance for Hotel Stay: Please check one: I need Satuday Night Only I need the Full Weekend I do not need Assistance
(If you request hotel accommodation, do not make reservations before being notified of the status of your application. If you receive assistance, The Family Café will make your reservations.)

Step 1 of 2