QUEER DISABILITY CONFERENCE 2002 -- REGISTRATION FORM

PART 1 -- CONTACT INFORMATION

Name:

Email address:

Title:

Organization or institution:

Mailing address (optional):

Phone number (optional): (Voice or TTY?)____________ Fax number (optional):___________

Do you want the above information included in a conference directory? Yes   No

PART 2 -- CONFERENCE REGISTRATION

Early bird (before April 15):
___$125 regular (doin' well)      ___$90 doin' okay      ___$ 60 low income
Regular (April 16-May 10):
___$150 regular (doin' well)      ___$115 doin' okay      ___$65 low income
On-site:
___$175 regular (doin' well)      ___$125 doin' okay      ___$70 low income

If you need financial assistance with housing or travel please fill out the Scholarship form.

If you need financial assistance for the registration fees, please pay the amount that you can pay.
Below, please indicate the amount you feel you are able to pay, considering your own personal financial situation, your ability to raise funds, and the benefits of attending this conference.

Your Total Registration Fee = $_______
Contribution towards a scholarship for someone else = $_______
Total for PART 2 = $_______

We cannot make refunds. If after paying your registration fee, you find you are unable to attend the conference, your payment will be considered a tax-deductible contribution. Thank you for your understanding.

PART 3 -- HOUSING AT SFSU

Will you be staying on the SFSU campus?   Yes    No
Do you want to share your dorm room with someone else?   Yes    No
If so, with whom do you want to share? Name:
OR, do you want to be assigned a roommate?   Yes    No
What gender roommate do you want?

If you want a roommate assigned to you, please describe any firm requirements for what type of person, i.e., smoking or nonsmoking, etc.:

Which nights do you plan to stay in campus housing? (Mark all that apply.)
___ Saturday, June 1   ___Sunday, June 2   ___Monday, June 3   ___Tuesday, June 4

Number of nights: x $28/pp double occupancy = $
OR, x $50/pp single occupancy = $

Total Housing Cost = $

PART 4 -- HOUSING ACCESS ISSUES

What level of access do you require? (Please check all that apply.)
___large enough area in bedroom to move or store wheelchair or other equipment
___CLOSE proximity to bathroom
___CLOSE proximity to elevator
___CLOSE proximity to conference area

Please indicate any other HOUSING access needs you have. (Examples: grab bars on a particular side; raised bed; two beds pushed together to make a double bed; non-smoking room; etc. We will do our best to meet your access needs.)

PART 5 -- CONFERENCE/MEETING ACCESS ISSUES

Please indicate if you have any of the following access or support needs AT THE CONFERENCE. (Mark all that apply, and provide details where necessary.)

Sign Language Interpreting-
Preferred mode:
___American Sign Language (ASL)
___Signed Exact English (SEE)
___Cued Speech
___Tactile sign language
___Other:____________________________________________

___Real-Time Captioning
If you marked both Sign Language Interpreting and Real-Time Captioning, which of these is your preferred mode of access?

___Assistive Listening Device

Alternatives to Print for Handouts-
Preferred mode:
___Braille
___Electronic Text (diskette)

___Personal Assistance Services

Do you need referrals and/or contact information for home health agencies and/or individual providers in San Francisco?   Yes   No

Please describe the type of assistance you expect to need during the day at the conference. (Mark all that apply.)
___Eating and drinking
___Pushing wheelchair
___Assistance with bathroom, full-assist transfer
___Assistance with bathroom, no assistance or light assistance with transfer
___Lying down in conference rest area
___Other -- please describe:

Any Other Access or Support Needs? Please specify:

Do you need childcare?
If yes, how many children?
What are their ages?

Note: childcare is $20 per child per day. If this is a hardship, we can provide scholarships.

PART 6 -- AFFILIATION, IDENTITY, AND PROGRAMMING INTERESTS

The following information is ENTIRELY OPTIONAL. Your answers will help us to plan the conference programming, including discussion sessions and caucus opportunities.

What is your occupation?

What institution or organization are you affiliated with, if any?

Which of the following conference focus areas are you most interested in? (Mark one or more.)
___Academics   ___Activism   ___Arts/Culture

How do you describe yourself and your identity/identities? (Mark all that apply)
___Lesbian   ___Gay man   ___Bisexual   ___Queer
___Straight ally   ___Male   ___Female   ___Other:

___Transgendered   ___Transsexual   ___Intersexed
___Genderqueer   ___Non-trans ally   ___Other:

___Physically disabled / wheelchair user   ___Physically disabled / non-wheelchair user
___Visually impaired / blind   ___Deaf with a capital "D"   ___Hearing impaired / deaf
___Learning disabled   ___Survivor of the mental health system
___Mentally ill / psychiatric disability
___EI-MCS / Environmental illness / Multiple chemical sensitivities
___Cognitively disabled / intellectual disability
___Self-advocate   ___Brain injury survivor   ___Chronic illness
___Invisible disability   ___Differently abled   ___Nondisabled ally
Other:

PART 7 -- CONFERENCE TEE-SHIRTS

Stylish conference tee-shirts, designed and produced by The Nth Degree, are available by pre-order for $15 apiece, IF ORDERED BEFORE APRIL 30. (Some shirts will be available on-site, for $20 apiece, but we won't be able to guarantee availability or sizes.) If you pre-order, you will receive your shirts at check-in.

Please indicate the quantity of each size t-shirt you are ordering:

Child small___     Child medium___     Child large___
Adult small___     Adult medium___     Adult large___
XL___        XXL___        XXXL___          Other:

Number of shirts ordered:______x $15

Total Tee-Shirt Order = $

PART 8 -- CONTRIBUTIONS AND SUPPORT

VOLUNTEERING:
We still need volunteers to help out with the conference. If you would like to volunteer, please mark all of the following that apply:
___I would like to volunteer to help IN ADVANCE OF the conference, with the following tasks --
___Fundraising
___Compiling Queer Disability resources
___Selling ads for the conference program
___Coordinating access/support needs
___Other:___________________________

___I would like to volunteer to help ON-SITE AT the conference, with the following tasks --
___Registration
___Providing personal assistance
___Coordinating access/support needs
___Staffing an information table
___Other:___________________________

DONATIONS:
If you would like to contribute, you may enter the amount of your donation below. The amount of your donation, over and above the cost of registration, housing, and T-shirt, is tax-deductible.
D.W.A./SFWC,Inc. is a 501(c)(3) nonprofit, Tax ID #: 94-1730620

Total Contribution = $

DO YOU PROMISE TO REFRAIN FROM SMOKING AND WEARING SCENTS ANYWHERE IN THE CONFERENCE SPACE AND LIVING SPACE? If yes, please sign here:__________________________________________________

PART 9 -- PAYMENT

PART 2 -- Total Registration Fee = $
PART 3 -- Total Housing Cost = $
PART 7 -- Total Tee-Shirt Order = $
PART 8 -- Total Contribution = $
TOTAL AMOUNT DUE = $_____________

Pay by Check or Money Order payable to D.W.A.
You may print and mail this form, along with your payment, to:
QD Conference
P.O. Box 9004
Denver, Colorado 80209