QUEER DISABILITY CONFERENCE 2002 -- REGISTRATION FORM
PART 1 -- CONTACT INFORMATION
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):
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.
Your Total Registration Fee = $_______
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
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.)
Number of nights: x $28/pp double occupancy = $
Total Housing Cost = $
PART 4 -- HOUSING ACCESS ISSUES
What level of access do you require? (Please check all that apply.)
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-
___Assistive Listening Device
Alternatives to Print for Handouts-
___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.)
Any Other Access or Support Needs? Please specify:
Do you need childcare?
Note: childcare is $20 per child per day. If this is a hardship, we can
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.)
How do you describe yourself and your identity/identities? (Mark all
___Transgendered ___Transsexual ___Intersexed
___Physically disabled / wheelchair user ___Physically disabled / non-wheelchair user
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___
Number of shirts ordered:______x $15
Total Tee-Shirt Order = $
PART 8 -- CONTRIBUTIONS AND SUPPORT
___I would like to volunteer to help ON-SITE AT the conference, with
the following tasks --
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 = $
Pay by Check or Money Order payable to D.W.A.