1999 Conference Regist.

Conference Registration Form
This form must be enclosed to pre-register for the conference. 
Please enclose a check to cover registration and fees or your
registration will not be processed.  Those applying for a
Scholarship to cover registration and fees must submit a
Scholarship Application Form.  Conference registration is limited
to 500, so register early.

I.  Identifying Information---Please type or print clearly
Name
Address
City
State
Zip 
Telephone
E-mail address
County
Gender---Male or Female
Affiliation/Organization
I use a wheelchair or scooter for mobility.
I will be bringing an attendant.  Attendant's name
I will be bringing my service dog.
I am applying to participate in Young Leaders 2000.  Attach
requested written information, and postmarked by 9/1/99.

II. Registration and Fees--Information is required to process
your registration.  Must be postmarked by September 1, 1999.

Registration:
$140.00-Early registration (postmarked by 9/1/99)
$175.00-Late registration by mail
Other fees:
$15.00 per person-Attitude is Everything Banquet
$12.00 per person-Policy Forum Breakfast

Conference Attendant Care number of days x $10.00
Total Payment submitted
I am applying for scholarship assistance and have attached my
completed scholarship form (both sides) 

Send completed registration form and check payable for total
amount to PCCD
Mail to: PCCD, 101 S. Second Street, Suite 4, Harrisburg, PA
17101


Accessibility
Check materials or services needed for the conference sessions. 
To ensure your request is filled, the Conference Registration
Form must be completed and postmarked by September 1, 1999.
Conference Personal Assistance Services
Interpreter Services.  Please specify
Assistive Listening Device. Please Specify.
Accessible Formatting: Large Print, Braille, Disk (ASCII), Disk
(WP), Audio Cassette Tape
Special Diet Requirements.  Please Specify
Sighted Guide
Audio Tape of Hotel Layout

Session Preference
For each time slot listed below, please mark your 1st, 2nd, and
3rd preferences by printing 1,2, or 3 in the box.
Sunday October 17, 1999, 1:30 PM--3:00PM: 
1, 2, 3, 4, 5, 6, 7
Sunday October 17, 1999,  3:30PM--5:00PM: 
8, 9, 10, 11, 12, 13, 14, 15
Monday, October 18, 1999, 9:30AM--11:00AM: 
16, 17, 18, 19, 20, 21, 22, 23
Monday, October 18, 1999, 3:30PM--5:00PM: 
24, 25, 26, 27, 28, 29, 30, 31

Conference registration does not include your hotel reservations. 
To reserve a room for the conference at the Harrisburg Hilton
please call Alice Bosley at the SILC office (800) 670-7303(v) or
(800) 440-0347 (tty)