REGISTRATION FORM June 9 - 10, 2006 REGISTRATION DEADLINE: Wednesday, May 3, 2006 Please mail or fax the completed form and registration fee to: VSA arts International Conference 818 Connecticut Avenue, NW, Suite 600 Washington, DC 20006 USA Fax: 202-429-0868 Please complete a separate form for each person attending the conference. Mr./Ms./Dr. First Name:______________________ Last Name:________________________ Title: __________________________ School/Organization Name: ____________________ Mailing Address: _______________________________________________________________ City: __________________________________ State/Province: _______________________ Zip/Postal: ________________________ Country: __________________________________ Tel: _______________________________ TTY: ______________________________________ Fax: _______________________________ Email: ____________________________________ 1) Which of the following best describes you? (choose one) ___ Teaching Artist ___ Classroom Educator ___ Researcher ___ Museum Educator ___ Education Administrator ___ Arts Program Provider ___ Access/504 Coordinator ___ Community Instructor ___ VSA arts Affiliate Staff ___ Other _______________ 2) Years of experience in the field of: Art: ____ Education: ____ Disability: ____ 3) How familiar are you with VSA arts? 1 2 3 4 5 Not Familiar Somewhat Familiar Very Familiar 4) How did you learn about the VSA arts International Conference? (check all that apply) ___ Internet ___ VSA arts mailings ___ VSA arts emails ___ VSA arts Affiliate ___ Friend/Colleague ___ Other ______________________________________________ 5) Which topic area interests you the most? (choose one) ___ Inclusive teaching strategies ___ Professional development models ___ Cultural arts access (facilities and programs) ___ Careers in the arts ___ Other ____________________________________________ ACCESS INFORMATION Do you use a wheelchair? ___ yes ___ no If yes, type: ___ manual ___ electric ___ 3-wheel scooter Do you require a wheelchair accessible bus or van? ___ yes ___ no Will you bring a service animal? ___ yes ___ no Will you bring a non-participant attendant? ___ yes ___ no Indicate any other relevant mobility needs you have: _________________________ ______________________________________________________________________________ Dietary Information: Box lunch provided Friday and Saturday. Every effort will be made to accommodate your dietary needs. Please indicate your meal preference: ___ Vegetarian ___ Vegan ___ Low Sodium ___ Low Carb ___ Other: ________________ Materials and Services: All materials will be provided in electronic format on CD. If additional formats are necessary, please specify: ___ American Sign Language ___ Captioning (CART) ___ Braille ___ Large Print ___ Other: _________________________________________ WORKSHOP SELECTION Choose one preferred session for each time period. FRIDAY, JUNE 9 ---------------- 9:00am – 10:00am ---------------- ___ Keynote ----------------- 10:45am - 12:15pm ----------------- ___ F1-A ___ F1-B ___ F1-C ___ F1-D ___ F1-E --------------- 1:45pm - 3:15pm --------------- ___ F2-A ___ F2-B ___ F2-C ___ F2-D ___ F2-E --------------- 3:30pm - 5:00pm --------------- ___ F3-A ___ F3-B ___ F3-C ___ F3-D ___ F3-E ___ F3-F ------------- Evening Event ------------- ___ Matt Savage Trio SATURDAY, JUNE 10 ---------------- 9:00am – 10:00am ---------------- ___ Keynote ----------------- 10:45am - 12:15pm ----------------- ___ S1-A ___ S1-B ___ S1-C ___ S1-D ___ S1-E --------------- 1:45pm - 3:15pm --------------- ___ S2-A ___ S2-B ___ S2-C ___ S2-D ___ S2-E --------------- 3:30pm - 5:00pm --------------- ___ S3-A ___ S3-B ___ S3-C ___ S3-D ___ S3-E -------------- Evening Events -------------- ___ Exhibit Opening ___ Finale Concert PAYMENT INFORMATION - 2 DAY - ___ Early registration (before May 3, 2006): $80 per person ___ Registration (after May 3, 2006): $100 per person - 1 DAY EDUCATOR OPTION - (PreK-12 classroom teachers) ___ Friday, June 9: $50 per person ___ Saturday, June 10: $50 per person - VSA arts AFFILIATES - ___ US affiliate discount, 2 days: director, staff, board member, $50 (before May 3, 2006) ___ International affiliate 2 days: director, staff, board member, fee waiver, $0 (before May 3, 2006) - CONFERENCE PRESENTERS - ___ Adjudicated presenter only, fee waiver, $0 ___ Check: Make check payable to VSA arts, Inc. Amount: $_______________________________________ Credit Card: ___ Visa ___ Mastercard ___ American Express Amount: $____________________________________________ Name on Card:________________________________________ Card Number:_________________________________________ Expiration Date:_______________________________________ Authorized Signature: __________________________________ Zip/Postal Code (of billing address) ____________________ --------------------------------------------------------------------- ALTERNATIVE FORMATS OR QUESTIONS? If you would like an alternative format of this brochure, or have any questions regarding the conference, please contact Stephanie Litvak at 1-800-933-8721, 1-202-628-2800 (voice), 1-202-737-0645 (TTY), or via email at conference@vsarts.org. The contents of this publication were developed under a grant from the United States Department of Education. However, those contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the United States Federal Government.