Disability Rights Legal Center

Protecting the Possibilities

Registration Form

Conference Registration Form

First Name:

Last Name:

Organization:

Title:

Address:

City:

State:

Zip:

Day Time Phone:

Alternate Phone:

Email:

Are you a:

Patient Survivor Caregiver
Advocate Healthcare Professional Other

Ethnicity:

Caucasian Hispanic African American
Asian Pacific Islander Other

Gender: Male Female

Age: 0-18 19-64 65+

Do you need Spanish translation? No Yes

Do you need accommodations? No Yes

Do you wish to receive the CLRC email newsletter? No Yes

How did you hear about this conference?

What is one thing you hope to learn or take away from this conference?