National Family Conference 2005
Conference Registration Form
(Please print out these pages and send them to the address
indicated below.)
PLEASE PRINT CLEARLY OR TYPE.
Name__________________________________________________
Address________________________________________________
_______________________________________________________
City_______________________ State_________ Zip____________
Daytime Phone_______________________________
E-mail______________________________________
CONFERENCE FEES: (Early Bird Registration Must be Postmarked
by July 18, 2005)
Early Bird
After July 18th
Registration
Full Conference
Family*
$100.00
$150.00
Adults (19+) $40.00
$50.00
Child (5-18) $15.00
$25.00
Ages 4 & Under Free
Free
One Day Only
Family* $75.00
$85.00
Adults (19+) $25.00
$35.00
Child (5-18) $10.00
$20.00
Ages 4 & Under Free
Free
*Family registration is limited to two adults and children of
the same
family.
NUMBER ATTENDING:
FULL CONFERENCE
#_____Family @ $__________ each = $__________
#_____Adults @ $__________ each = $__________
#_____Children
@ $__________each = $_________
#_____Children
4 & under (free)
ONE DAY ONLY
Specify
Friday, Saturday, OR Sunday
#_____Family @ $__________ each = $________
#_____Adults
@ $__________ each = $_________
#_____Children @ $__________each = $________
#_____Children 4 & under (free
TOTAL$____________
Anticipated Arrival Date & Time_______________________________
Only Cash or Checks accepted at on-site registration.
No refunds will be made.
CHILD CARE - IMPORTANT!
If you will require day care for your child during the conference, it is VERY
important that you register ahead of time (by July 18, 2005) so that we
have a sufficient amount of space and child care workers available.
PAYMENT METHOD
Checks: Payable to the National Family Conference
Credit Card: __________ Visa __________ Mastercard
Card Number:_____________________________________________
Expiration Date:___________________________________________
Print Name as it appears on card:______________________________
Signature:________________________________________________
Mail all completed forms (see the following), postmarked no
later than July 18, 2005, to:
Burt Boyer/National Family Conference
American Printing House for the Blind
1839 Frankfort Avenue
Louisville, KY 40206-0085
Please contact Burt with questions at:
Email: bboyer@aph.org
Toll Free 1-800-223-1839 x264
Phone (502) 899-2264
Fax (502) 899-2269
REGISTRATION DETAIL
Category
Names(s)
Adults:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Children Ages 12-18 (Needing Childcare)
Name(s)
Age
_____________________________________
________
_____________________________________
________
_____________________________________
________
_____________________________________
________
Children Ages 12-18 (Participating in
Conference Activities; not
needing childcare)
Name(s)
Age
_____________________________________
________
_____________________________________
________
_____________________________________
________
_____________________________________
________
Children Ages 0-11 (Needing childcare)
Name(s)
Age
_____________________________________
________
_____________________________________
________
_____________________________________
________
_____________________________________
________
ARRIVAL DATE:___________DEPARTURE DATE:______________
MEALS ATTENDING:
Friday Reception # attending__________
Saturday Luncheon # attending________
Saturday Family Activities # attending________
Sunday Brunch # Adults & Children over age 11
attending_________
Sunday Brunch # Children age 4-10 (who are 1/2 price) attending______
Sunday Brunch # Children age 3 and under (who are free) attending_____
PLEASE CHECK THE SATURDAY/SUNDAY WORKSHOPS YOU
PLAN TO ATTEND SO WE CAN ADEQUATELY PLAN FOR OUR
MEETING ROOM NEEDS.
First Breakout Session
Saturday Morning 10:15-11:15
___Accessible Training
___The Expanded Core Curriculum
___Early Literacy/Perkins Panda
___Braille for Parents
___Teen Panel
___Preparing Youth for a Guide Dog
Lifestyle
Second Breakout Session
Saturday Morning 11:30-12:30
___O & M for Preschoolers
___O & M for Adolescents
___Communication: Focus on Multi. Dis.
___Overview of Technology
___Daily Living Skills
Third Breakout Session
Saturday Afternoon 2:45-3:45
___On the Way to Independence:Strategies for Paving the Way
___Grandparents Panel
___IDEIA: What Parents Need to Know
___What Lies Ahead: On the Way to Literacy
___Partnerships & Advocacy
___Multiple Disabilities
Fourth Breakout Session
Sunday Morning 9:15-10:15
___Dad's Panel
___Social Skills
___The Three C's to Independence
___APH Products
___Believing You (Your Child) Can Do: Parent-Child Beliefs about
Physical Activity-Going in Positive
Directions
___Improving Transition Service Delivery by Partnering with
Parents
PROGRAM MEDIA AND SPECIAL NEEDS
The conference will endeavor to accomodate the services below if
requested prior to the pre-registration deadline of July 18, 2005. Please
check any of the following that you may require during the conference:
___ braille program
___restricted
field interpreter
___platform interpreter
___assistive
listening device
___tactile interpreter
___I
have a T-switch on my hearing aid
Other special needs:_______________________________________
For the eye condition roundtable (during Saturday lunch), please
circle
group you would like to attend:
Albinism
Medically Fragile
Aniridia
Multiple Handicaps
Anophthalmia/Microphthalmia
Optic Nerve
Atrophy/Hypoplasia
Cataracts & Glaucoma
Retinal Conditions
CHARGE
Retinoblastoma
Colaboma
Retinopathy of Prematurity
Cortical Visual Impairment
Toxoplasmosis
Corneal Diseases
Other:___________________
Deaf/Blind
OFFICE USE ONLY:
Date Received:___________ Check #______ C.C.________
Amount:$_____________ Receipt Card Issued:___________
ACCOMODATION INFORMATION
If you wish to stay at the Galt House Hotel during the conference, you must make
separate reservations
with the hotel before July 18, 2005. Following is HOTEL registration
information:
LODGING:
Galt House Hotel
Fourth Street at the River
Louisville, KY 40202
www.galthouse.com
 | Rates: $85 Suites to $77 Regular Room |
| Rooms must be guaranteed with a credit card |
| Special accomodations must be arranged with hotel. |
For room reservations, call 1-800-843-4258 by July 18, 2005 and mention the APH
National Family Conference and date. Do not call this number for Conference
Information.
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National Family Conference Page
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