11th Annual Disability and Aging Summit Registration Form

11th Annual Disability and Aging Summit Registration Form

October 14th and 15th from 8:00 AM to 3:45PM
Summit Registration

Please follow all instructions and if you experience any difficulties or would like some assistance with the registration process, please contact our support staff at chdsupport@alaska.edu or 907-264-6244.

The Summit will be held at in-person at the the Special Olympics Jim Balamaci Training Center, located at:

3200 Mountain View Dr.
Anchorage, AK 99501

Agenda : https://chd.box.com/s/hk6abhoed8nvdl2vks07kgy8om1l6485
Full Name*

First NameLast Name
Location (What community are you from?)
Email*
example@example.com
Phone Number - This will only be used if we can't reach you via email.
Please enter a valid phone number.Format: (000) 000-0000.
Do you require a reasonable accommodation due to a disability/medical condition to fully participate in this event? If so, please let us know the accommodation you require in the box provided below, and we will attempt to meet your needs.*

YesNo
Please list any accommodations that are needed
I give the University of Alaska Anchorage** (UAA) permission to take photographs or video of me and to use the photographs, video or audio in its print and internet publications or productions, including advertising, signage and promotional materials, and for commercial purposes. I also give UAA** permission to use my name, academic class standing and major in an accompanying caption, if applicable. I assign all right, title and interest I may have in any photograph or video to UAA. I agree that the photographs and video are the property of UAA and hereby release UAA from any and all claims that I may have from its use of my image or voice, including but not limited to any claim for compensation.*

YesNo
* Permission granted extends to all affiliated centers, foundations and training programs to which UAA is a part of or participant in. UA is an affirmative action/equal opportunity employer, educational institution and provider and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination.
Should be Empty: