AFB Leadership Conference Registration



To register for the conference, please fill out this form or mail a completed registration form to: American Foundation for the Blind Attn: Patsy Carvache 1000 Fifth Ave Suite 350 Huntington, WV 25701 Please type or clearly print the following information. (All items must be completed for registration to be processed.) This is exactly how it will appear on the Participants List.
Registrant Information
Salutation:
First Name: [Required]
Last Name: [Required]
Title:
Affiliation:
AFB Staff Member?:
Are you a Speaker?:
If you have a speaker code, please enter it here:
Billing Address on Credit Card: [Required]
Address Line 2:
City: [Required]
State or Province (Select other if international): [Required]
Zip Code: [Required]
Phone: [Required]
Email: [Required]
Participants will receive a flash drive that will contain the agenda, program, participant list and handouts. The agenda and program will also be available in print or if you need an alternate format, please select one preference below:
Material Format:
Do you have any dietary restrictions?: [Required]
If yes, please specify:
If you need an American Sign Language interpreter, the deadline to request it is April 8th, 2013.
Do you need a sign language or tactile interpreter for any part of the conference?:
If yes, please specify:

Pre-Conference Sessions Thursday April 18, 2013 Pre-conference session charges are $75 for full day. We will contact you by e-mail to learn what your session choices are.
Do you plan to attend the Pre-Conference?:
AFB Leadership Conference Registration Fees
AFB Leadership Conference
Registration Date and Fee
Pre-Registration: $175 (available until April 8, 2013) Late Registration Fee: $200
Do you plan to attend the entire Leadership Conference (Friday, April 19, AND Saturday, April 20, 2013)?: [Required]

If not, there is a special one-day rate (Available for Friday, April 19, OR Saturday, April 20, 2013): $100
Do you want to register for the one-day rate?:
Access Awards and Migel Awards The Access Awards will take place the afternoon of Friday, April 19.
Do you plan to attend the Access Awards?: [Required]
Do you plan to attend the Migel Luncheon?: [Required]
Do you plan to attend the IAER lunch on Friday? Cost is $15: [Required]
* Your registration fee includes the following meal functions:
Access Awards reception on Thursday evening (consisting of light hors d'oeuvres) Migel awards luncheon on Saturday
Checks: Please make checks payable to the American Foundation for the Blind (AFB Leadership Conference).
State agencies may use a purchase order if necessary.
If you have any questions, contact Scott Truax at 646 206 2968 or by e-mail at struax@afb.net.
* Cancellation Policy: In the event that you need to cancel your registration, you must cancel by April 8, 2013, for a full refund. There is no refund after April 8.

Payment through purchase order or check
Do you want to pay by purchase order or check? [Required]
If you have selected to pay by purchase order or check, please skip the Credit Card Section below.

Please provide your credit card information
Card Type:
Card Number [5555444433332222]:
Expiration [mm/yy]:
First Name on Card:
Last Name on Card:
Verification Number:
The verification number is a 3-digit number printed on the back of your card. The American Express verification number is a 4-digit number printed on the front of your card. You will have a chance on the next page to confirm your purchase. You must hit "continue" in order to complete your registration. After your registration is complete, you will receive an e-mail from AFB, which will serve as your receipt. If you have any concerns, or if you do not receive the e-mailed receipt, contact Scott Truax at 646-206-2968 or by e-mail at struax@afb.net.