2017 AFB Leadership Conference Main Page Registrant Information First Name: [Required] Last Name: [Required] Title: [Required] Affiliation: [Required] City: [Required] State or Province (Select other if international): [Required] Select State or Province (Select other if international) AAA All USA States Only AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY AAB All Canadian Provinces Only AB BC MB NB NL NS NT ON PE PQ SK YT Other Phone: [Required] Email: [Required] Participants will receive a link to a Dropbox folder that will contain the agenda, program and handouts. The agenda and program will be available in print. If you need an alternate format (requests for braille and large print must be submitted by 2/1/17), please select one preference below:: Material Format: Select Material Format Braille Electronic Large Print Please tell us about your accessibility needs and we'll do our best to accommodate you. Interpreter requests must be made by 2/13/17. Do you have any accessibility concerns? Select Do you have any accessibility concerns? Yes No If yes, please specify: Access Awards Reception — 4:30-6:00 p.m. on Friday, March 3
Join us for light hors d'oeuvres and drinks as we celebrate our 2017 Access Award recipients. There is no charge to attend.
Migel Medal Luncheon — 12:45-2:30 p.m. on Saturday, March 4
Join us for the presentation of the highest honor in the blindness field. This sit-down meal includes an entree, dessert, and beverage. Attendance is optional. Cost: $15
Do you plan to attend the Access Awards on Friday, March 3?: [Required] Select Do you plan to attend the Access Awards on Friday, March 3? Yes No Do you plan to attend the Migel Luncheon on Saturday, March 4?: [Required] Select Do you plan to attend the Migel Luncheon on Saturday, March 4? Yes No Would you like a vegan, gluten-free meal?: [Required] Select Would you like a vegan, gluten-free meal? Yes No Light hors d'oeuvres and drinks will be served during the Access Awards Reception . A lunch will be served during the Migel Awards event. AFB Leadership Conference Registration Fees Conference Fees One day: $150 (After February 10 $175) Two days: $225 (After February 10 $260) Three days: $275 (After February 10 $325) Please select the days you plan to attend: Thursday, March 2: [Required] Select Thursday, March 2 Yes No Friday, March 3: [Required] Select Friday, March 3 Yes No Saturday, March 4: [Required] Select Saturday, March 4 Yes No Payment by Purchase Order or Check Checks: Please make checks payable to the American Foundation for the Blind (AFB Leadership Conference). Purchase Orders: State agencies may use a purchase order if necessary.
If you have chosen to pay by check or purchase order, please print out this page and mail it in with your payment. We will send a confirmation e-mail once the payment process is complete. You may combine multiple participants onto one check or purchase order, but please print out a separate registration form for each person. We will send an invoice for those sending purchase orders.
Please mail to: Patsy Carvache AFB 1000 Fifth Avenue, Suite 350 Huntington, WV 25701 If you have any questions, contact Kevin Dougherty by e-mail at firstname.lastname@example.org. Do you want to pay by purchase order or check? [Required] Select Do you want to pay by purchase order or check? Yes No If you have selected to pay by purchase order or check, please skip the credit card section below, and go right to the Continue button. If Paying by Credit Card, Please Provide the Information Requested Below Card Type: Select Card Type American Express Visa MasterCard Discover Card Number : 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. Credit Card Address Line 1: Address Line 2: City: State or Province (Select other if international): Select State or Province (Select other if international) AAA All USA States Only AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY AAB All Canadian Provinces Only AB BC MB NB NL NS NT ON PE PQ SK YT Other Zip Code: Country: Select Country United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Apo Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'ivoire Croatia (local name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe islands Fiji Finland Fpo France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Honduras Hong kong Hungary Iceland India Indonesia International Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao, People's Democratic Republic of Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslavia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadin Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sa Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe 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, please contact Kevin Dougherty by e-mail at email@example.com. * Cancellation Policy: In the event that you need to cancel your registration, you must cancel by February 10, 2017, for a full refund. Participation or attendance at programs or events sponsored by the American Foundation for the Blind (AFB) during the AFB Leadership Conference constitutes: (a) the voluntary consent of the participant or attendee to be photographed, filmed or videotaped by AFB or its representatives and (b) permission to the reproduction and use of all such photographs, digital images, films and likenesses for publicity purposes in publications, brochures, advertisements, promotional and marketing materials and all other media venues including the World Wide Web, all without further notice or compensation to participant or attendee who hereby releases to AFB all proprietary rights and copyrights in all such photographs, digital images, films and likenesses (including negatives, positives and prints) which shall be and remain the property of AFB