AL-APSE & ACDD. June Annual Training Conference. Birmingham, Alabama Conference Registration Form. Celebrating 20 Years APSE

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1 2018 AL-APSE & ACDD Annual Training Conference June Birmingham, Alabama Conference Registration Form AL Celebrating 20 Years APSE

2 Conference Location Hyatt Regency The Wynfrey Hotel 1000 Riverchase Galleria Birmingham, AL Room Rates: $96.00 Single/Double To Book Electronically: Book Early! Discount Room Rate Expires on 5/22/18 Tentative Conference Schedule: Wednesday, June 13, 2018 Friday, June 15, :00 11:55 Registration 8:00 9:45 General Session 12:00 2:15 Awards Luncheon 9:45 10:15 Break 2:15 3:00 Break 10:15 Noon Closing Session 3:00 4:30 General Session Thursday, June 14, :30 9:30 Breakout Sessions 9:30 9:45 Change Sessions The agenda is tentative and subject to change. This year s conference will open with the Annual Alabama APSE Awards Luncheon. Please take time to nominate a potential award winner. More information on the awards can be found at 9:45 10:45 Breakout Sessions 10:45 11:15 Break 11:15 12:15 Breakout Sessions 12:15 1:45 Lunch (On Your Own) 1:45 2:45 Breakout Sessions 2:45 3:15 Break 3:15 4:15 Breakout Sessions 6:00 Until Evening Event Alabama APSE and ACDD welcome your Advertisement (AD) for this year s conference program. To purchase an ad, please click on link below. Please your ad to Byron.white@mh.alabama.gov To Register the Ad: llr=eq8in9eab&oeidk=a07eezep7oz34ea0e2c

3 2018 Registration Form Paper Registration Form Electronic Registration Encouraged! AL-APSE Members: $ before May 19 $ after May 19 Non-Members: $ before May 19 $ after May 19 PLEASE NOTE: Members of APSE receive a $30.00 Discount on Registration Please apply Discount CODE: ALAPSEMEMBER Only Available to Members! Name: APSE Membership # N/A if None Member Address: Address: City: State: Zip: Phone:( ) - Organization/Company: ADA Accessibility Needs: i.e. Braille, Interpreter, etc. Must Request by May 11, 2018 Please contact Byron.white@mh.alabama.gov to discuss ADA needs Continuing Education (Social Work, Counseling, Nursing) and CRC, CESP Credit will be available. For more information and updates contact Alabamaapse@aol.com, visit or contact Beth.hanks@rehab.alabama.gov ( ) By registering for this conference each attendee understands that photographs and videos may be taken throughout the conference for use in publications, presentations and other events. The photos will remain the property of AL-APSE. Please inform photographer(s) if you do not wish to be photographed! Make Checks Payable to: Alabama APSE Mail Registration Form & Check to: PO Box Montgomery, AL Visa and MasterCard Accepted $2.00 Processing Fee Card Number CVV # on back of Card (3 digits) Expiration Date: Signature: Please Visit Page 3 for Electronic Registration Information Purchase Orders Consumer Involvement

4 Electronic Registration Information You are encouraged to register electronically for this year s conference. Three options are available. Please select the appropriate registration link: Regular Registration Check or Credit Card Payment via check due within 10 days after registering to avoid cancellation. Checks should be made payable to Alabama APSE and mailed to: AL-APSE, PO Box , Montgomery, AL Registration and payment via Purchase Order: Registration and Request for Consumer Involvement: (available to Self-Advocates and or their Family Members/Care Givers only) For those requesting Consumer Involvement Conference sponsorship, register electronically and then mail your registration form along with CIF application (page 5) to AL-APSE, PO Box , Montgomery, AL 36124! You can also scan and to Byron.white@mh.alabama.gov Selected applications will be notified by May 18, 2018!

5 CIF INDIVIDUAL APPLICATION (PLEASE PRINT OR TYPE) Name Address Telephone Number City State Zip Do you live inside the city limits? Yes No If not, please list the county you live in? ETHNIC STATUS (OPTIONAL:) ( ) PLEASE CHECK THE APPROPRIATE BOX: HISPANIC AFRICAN AMERICAN ASIAN-AMERICAN AMERICAN INDIAN CAUCASIAN I am a person with a developmental disability. I am a parent of a child with a developmental disability I am the guardian for a person with a developmental disability My family member is an adult with a developmental disability Other WHAT CONFERENCE/EVENT ARE YOU SEEKING FUNDS TO ATTEND? You must attach to this application any printed information on the event that clearly explains what you want to attend, such as the agenda, brochure, and/or flyer). Date of Conference/Event Location of Event/Activity # of People using CIF Funds PLEASE INDICATE FUNDS BELOW: HOW MUCH YOU CAN PAY(YOUR FUNDS)? HOW MUCH FUNDED BY OTHERS (OTHER AGENCIES? YOUR FUNDS FUNDS FROM OTHER AGENCIES FUNDS FROM ACDD CIF REGISTRATION PERSONAL ASSISTANCE HOTEL/LODGING MILEAGE CHILD/RESPITE CARE AIR OR BUS FARE MEALS OTHER (please list ) TOTAL

6 Exhibit/Sponsorship Form See Electronic Registration Link Below Name: Address: Name of Company/Organization: Address: City: State: Zip: Telephone: Non Profit Exhibit: $ For Profit Exhibit: $ Celebration Sponsor $1, (Includes exhibit, full page ad, conference registration, conference recognition! (Must submit ad by May 1, 2018) Quarter Page Ad: $ Half Page Ad: $ Full Page Ad: $ Ads due by May 1, 2018 Person(s) Manning Exhibit Booth: Make Checks Payable to Alabama APSE & mail to AL-APSE, PO Box , Montgomery, AL questions to: or To Register Exhibit or Sponsorship Electronically: See Page 2 for Information on a Conference Program Ad! If hotel accommodations are needed please see page 2 to reserve your room!