Registration

Super Early Bird Registration is now open for $100. Save $50 on the regular registration fee if you register before August 31st. Payment options are available with a $50 non-refundable deposit.

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Name *

First

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Level of Vision *

• Sighted
• Legally Blind/Partially Sighted
• Totally Blind

Preferred Conference Program Format *

• Braille
• Electronic
• Large Print

Preferred Method of Communication

• Phone
• Text
• Email
• Snail Mail

Birthdate

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Gender

• Male
• Female

Mobility

• White Cane
• Guide Dog
• Sighted Guide
• Wheelchair/Scooter

Allergies (especially food allergies) or other health issues

Cause of Blindness/Eye Disease

How did you hear about the conference?

I am interested in group transportation if possible. This may be a chartered bus/van and I understand this incurs an additional fee.

• Yes
• No

I need an assistive listening device

• Yes
• No

I am a Personal Assistant or SSP

• Yes
• No

I'm an Assistant/SSP for:

I am a Volunteer

• Yes
• No

I would like to order a conference t-shirt for $22. Adult sizes only (add $1 for 2XL, $2 for 3XL) choice. This will be invoiced separately closer to the conference time.

• Small
• Medium
• Large
• XL
• 2XL +$1
• 3XL +$2

I am purchasing Meals (ala carte option at check out).

• All Inclusive
• Ala Carte

I am interested in Post Conference Activities (cost varies and is not included in conference costs)

• Bass Pro Shop
• Magnolia Soap or Candle Making Class
• Rose District Shopping
• Exotic/Zoo Experience

For Exhibitor Sponsors

If you are an exhibitor sponsor, please continue to complete the information below and hit the submit button at the very bottom of this page.

Company Name

Name(s) of those manning the booth

Company Phone

Website / URL

Company Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Level of Sponsorship

• Platinum
• Gold
• Silver
• Bronze
• Marketing/Goodie Bags

Add on's

• Extra Table
• Electricity
• Meal Tickets

Are you willing to donate an item for the auction raffle?

• Yes
• No

Will you be sending Marketing Material or SWAG to be stuffed into the Goodie Bags?

• Yes
• No

Submit