(Please print clearly)

Name

Address City

Zip E-mail

Phone: (h) (w)

(c)

Child’s Age School/Agency

 Please register me for the Conference. (Make checks payable to the Disability & Communication Access Board (DCAB).

Enclosed is my registration fee: $20 per parent or $30 for two family members together) or $30 per professional. Amount/Purchase Order # enclosed  

I am a parent/grandparent of a child with special needs and would like an airfare scholarship (Based on availability and upon completion of SPIN’S Airfare Scholarship Form)

Airfare Scholarships are limited so apply early!

  I need a map to the Campus Center.

  I need an accommodation due to a disability:

         materials in an alternative format (Braille, tape, etc.)

         sign language interpreter

       map of accessible parking stalls for persons with disabilities

       other:

ACCOMMODATION REQUESTS MUST BE SUBMITTED BY APRIL 6, 2010. 

EMAIL completed forms with payment as soon as possible to: spin@doh.hawaii.gov

**Register Early to Guarantee A Seat!**