PFMO 2015 Conference Registration Form Question Title * 1. Please provide the following information: Name: (required) * PF Chapter or Company: Address: (required) * City/Town: (required) * State: (required) * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: (required) * County you live in: Email Address: * Phone Number: * Question Title * 2. How are you connected to the self-advocacy movement? (Check ALL that apply) Belong to a "Local" or "State" self-advocacy group Person with a disability Adviser to a Local or State self-advocacy group Family member of a person with a disability Professional in the disability field (includes PCA/direct care person) Other (please specify) Question Title * 3. If you require written materials in an alternate format, please select your preferred format: Braille Large Print Electronic Format Question Title * 4. Do you require a sign language interpreter? Yes No Question Title * 5. Do you have any special dietary needs? None Vegetarian Kosher Gluten-free Other (please specify) Question Title * 6. Do you have any other requirements that we need to know about? Question Title * 7. Please select your T-shirt size: Small Medium Large X-Large XX-Large XXX-Large Question Title * 8. Please select the breakout topic you are planning to attend in Breakout Session 1: (Saturday Afternoon-2:15 to 3:30) A. Alternatives to Guardianship: Learn Your Rights B. Clean Up Your Act! It's Not Personal...It's Professional C. How One Chapter Conducts Its Meetings D. What is a Good Life? E. How to Get a Job and Keep It Question Title * 9. Please select the breakout topic you are planning to attend in Breakout Session 2: (Saturday Afternoon-3:45 to 5:00) F. A Home to Call Your Own G. Preparing for a Disaster: Are You Ready H. All About Assistive Technology I. I'm Human, You're Human: Go Tell the World J. People with Disabilities and the Law Question Title * 10. Please select the breakout topic you are planning to attend in Breakout Session 3: (Sunday Morning-9:00 to 10:15) K. Oral Health & Your Body L. Healthy Relationships: Creating a Plan M. Self-Advocacy at the Local Level N. Planning for a Good Life O. Asset Building: Why It's Important & How to Do It Question Title * 11. REGISTRATION OPTIONS & FEESRegistering by APRIL 7:- FULL REGISTRATION - $95 (includes conference materials, all sessions, 3 meals on Saturday, Sunday brunch, and T-shirt) - SATURDAY ONLY - $75 (includes materials, Saturday sessions and meals, and T-shirt) - SUNDAY ONLY - $50 (includes materials, Sunday sessions and brunch, and T-shirt)IMPORTANT NOTES: If registering after APRIL 7, T-shirts will cost $10, and may not be available in your size.After APRIL 21, no meals will be included with your registration. Same fees apply.NO REFUNDS after APRIL 21.Please select your registration choice below: Full Registration - $95 Saturday Only Registration - $75 Sunday Only Registration - $50 Next