Program and lodging information: www.atia.org
ATTENDEE REGISTRATION FORM
Please print clearly or type (this form may be copied for additional registrants.)
First Name: ______________________________________________________________
Last Name: ______________________________________________________________
Badge Name: ________________________Position/Title: ____________________________________
Company Name: __________________________________________________________
Address: _______________________________________________________________
City/State/Zip Code/Country: ____________________________________________________________
Phone: ____________________________________Fax: _____________________________________
E-mail: __________________________________________________________________________________
If you need to be accompanied by an assistant, please enter their name here for an assistant badge. Please note: assistant registrants are not eligible for continuing education credit.
(There is no fee for assistant badge):
Assistant First Name: ___________________ Assistant Last Name: _______________
Assistant Email: ___________________________________________________________________________
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Registration Categories / Fees
Please identify the fees in the proper tier associated with your registration category and include the total below.
*Please note discount offers may not be combined for multiple discounts. Only one discount can be applied per attendee.
Parent/Student Registration* (50% discount on full conference registration)
Exhibit Hall (Wednesday thru Saturday)
11/14/15 – 1/8/15
$270
Free
1/9/15 - Onsite
$278
Free
Parent/Student Single Day Attendee Registration:
One Day Thursday (includes complimentary Saturday registration).
$158 $158
One Day Friday (includes complimentary Saturday registration).
One Day Saturday.
$158
$50
$158
$50
Pre-paid Lunch Ticket: Select Day/s required:
Tuesday / Wednesday / Thursday / Friday
AOTA CEU Fee (Attendance forms provided online and onsite)
Note: Complimentary CEUs are provided for all sessions.
Specialist ACVREP and ASHA CEUs are provided for selected sessions at no cost.
TOTAL $ ________________________
$16/day
$15
$16/day
$15
Pre-Conference Seminars can be added to your registration for a separate fee. Pre-Conference Seminars are taking place before the Conference. Registration fees separate are separate from conference fees. Seminars are taking place Tuesday, February 2 and Wednesday, February 3
11/14/15 – 1/8/15 1/9/15 - Onsite
Parent/Student Two Day Pre-Conference Seminar (Listed under “Two Day Pre-Conference Seminar” below) Select the 2day seminar: ___________________
Parent/Student Tuesday One-Day Pre-Conference Seminar
(Listed under “One Day Pre-Conference Seminar” below)
Select Seminar for Tuesday, February 2:
__________________________________
Parent/Student Wednesday One-Day Pre-Conference Seminar
(Listed under “One Day Pre-Conference Seminar” below)
Select Seminar for Wednesday, February 3:
____________________________________
$265
$150
$150
$265
$150
$150
Parent/Student Tuesday One-Day Pre-Conference Seminar and Wednesday One-Day Pre-Conference Seminar (Listed under “One Day Pre-Conference Seminar” below). Select
Seminar for Tuesday, February 2 and Wednesday, February 3
____________________________________
PRE- CONFERENCE SEMINAR TOTAL $ ________________________
$265
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$265

Date/Time : Tuesday, February 2 and Wednesday, February 3, 2016, 8:00am – 4:00pm
Session Type : Two day
Session Code : PRE-01TW Track: Sensory Impairment
Session Title : Introduction to Technology for Blind and Visually Impaired
Speaker : Ike Presley, National Project Manager at American Foundation for the Blind
Alyson Gullette, Adjunct Professor at Salus University, Larry Lewis, Flying Blind, LLC
Session Code : PRE-02TW Track: Augmentative and Alternative Communication
Session Title : Multi-Modal Communication and Learning Strategies for Children with Significant Challenges
Speaker : Linda Burkhart, Independent Consultant at Linda J. Burkhart
Session Code : PRE-03TW
Session Title : iPad Boot Camp - 101
Track: Assistive Technology for Improved Function
Speaker : Therese Willkomm, Director of ATinNH at University of New Hampshire
Session Code : PRE-04TW Track: Education/Learning
Session Title : Fundamentals of AT Implementation: QIATly, Collaboratively, Setting up for Success
Speaker : Judith Schoonover, Assistive Technology Trainer at Loudoun County Public Schools
Matthew Press, Occupational Therapist and Assistive Technology Team Member at Peoria Unified
School District
Date/Time : Tuesday, February 2, 2016, 8:00am – 4:00pm
Session Type : One day
Session Code : PRE-05T Track: Leadership
Session Title : The Evolution of AT Teams: Redesigning Your AT Services
Speaker : Denise DeCoste, Independent Consultant at Accessible Technology Consulting
Gayl Bowser, Independent Consultant at Assistive Technology Collaborations
Session Code : PRE-06T Track: Assistive Technology for Improved Function
Session Title : Beyond 90/90/90; Seating & Access to AT
Speaker : Karen Kangas, Karen M Kangas OTR/L
Session Code : PRE-07T Track: Education/Learning
Session Title : AT Bootcamp: Start at A (Assessment; Access and AAC)
Speaker : Mike Marotta, AT Specialist at Inclusive Technology Solutions, LLC
Brian Wojcik, Assistant Professor at University of Nebraska at Kearney Department of Teacher
Education
Session Code : PRE-08T Track: Education/Learning
Session Title : Language, Literacy and Learning: Technology-enhanced classrooms
Speaker : Amanda Hartmann, Speech Pathologist at Amanda Hartmann/ Spectronics
Session Code : PRE-09T Track: Augmentative and Alternative Communication
Session Title : 5 Steps to Successful Implementation of AAC Apps in Classrooms
Speaker : Kelly Fonner, Consultant at Fonner Consulting
Scott Marfilius, Consultant at Marfilius Consulting
Session Code : PRE-10T Track: Education/Learning
Session Title : AT Solutions for Students with Dyslexia: Case Studies and Options
Speaker : Jamie Martin
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Session Code : PRE-13T Track: Education/Learning
Session Title : Universal Design for 21st Century Learning
Speaker : Beth Poss, Special Education Administrator and AT Consultant at Montgomery County Public Schools
Christopher Bugaj, Assistive Technology Trainer at Loudoun County Public Schools
Date/Time : Wednesday, February 3, 2016, 8:00am – 4:00pm
Session Type : One day
Session Code : PRE-11W Track: Augmentative and Alternative Communication
Session Title : AAC Apps: Communicate, Learn, Connect!
Speaker : Amanda Hartmann, Speech Pathologist at Amanda Hartmann/ Spectronics
Session Code : PRE-12W Track: Education/Learning
Session Title : Electronic Study Skills and Notetaking - Time to get on Board
Speaker : Scott Marfilius, Consultant at Marfilius Consulting
Kelly Fonner, Consultant at Fonner Consulting
Session Code : PRE-14W Track: Education/Learning
Session Title : The New Writing Protocol: PK-12 research, assessment, and integrative approaches for Struggling
Writers
Speaker : Denise DeCoste, Independent Consultant at Accessible Technology Consulting
Session Code : PRE-15W
Session Title : Apps Across the Curriculum
Track: Education/Learning
Speaker : Diana Petschauer, ATP, CEO at AT for Education
Stacy Driscoll, Assistive Technology Specialist at AT for Education & LifeLong Assistive Technology
Alyssa Marinaccio, Assistive Technology Coordinator at AT for Education and Keene State College
Session Code : PRE-16W Track: Leadership
Session Title : AT Teams that Thrive: Gaining Support and Reducing Conflict
Speaker : Gayl Bowser, Independent Consultant at Assistive Technology Collaborations
Penny Reed, Independent Consultant at Penny Reed Consulting
Session Code : PRE-17W Track: Assistive Technology for Improved Function
Session Title : The Switch is not the Activity; Supporting Transparency
Speaker : Karen Kangas, Karen M Kangas OTR/L
Lisa Rotelli, Director at Adaptive Switch Labs, Inc
Session Code : PRE-18W Track: Education/Learning
Session Title : AT Bootcamp: Continue with I (Instruction/Literacy, Integration & Implementation)
Speaker : Kirk Behnke, Senior Education Specialist, Special Education Solutions; Lead, Texas Assistive
Technology Network
(TATN) at Region 4 Education Service Center
Brian Wojcik, Assistant Professor at University of Nebraska at Kearney Department of Teacher
Education
Session Code : PRE-19W
Session Title : Google Chrome Bootcamp
Track: Everyday Technology
Speaker : Mike Marotta, AT Specialist at Inclusive Technology Solutions, LLC
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Session Code : PRE-20W Track: Education/Learning
Session Title : CSI Autism: Communication, Social, Instruction
Speaker : Mo Buti, Owner AiepA and Director of Program Development Neumann at AiepA consultant owner and
Director of Program Development Neumann Family Services
Session Code : PRE-23W Track: Leadership
Session Title : Evolution of an AT Team: Real World Experiences Shaping Practices
Speaker : Mark Nichols, Supervisor, Assistive Technology at Loudoun County Public Schools
Sally Norton-Darr, Assistive Technology Trainer at Loudoun County Public School
Chris Bugaj, Assistive Technology Trainer at Loudoun County Public School
5 WAYS TO REGISTER
ONLINE: www.atia.org/registerORL
EMAIL: registration@atia.org
FAX: 847-277-7414
TELEPHONE: 847-620-4471
MAIL: ATIA Registration, 8324 Solutions Center, Chicago, IL 60677-8003
PAYMENT INFORMATION: Full payment must accompany registrations. ATIA Federal ID#: 77-0482095
Check (payable to ATIA) registration)
MC Visa AMEX PO (Original purchase order must accompany
Total Fees Due: $ __________________________________________________________________________
Check/Card/PO# ____________________________________ Exp Date ____________CVV Code ___________
Name on card (please print) ________________________________________________________________
Signature: ________________________________________________________________________________
If you submit this form via fax, email, online, or mail, you are agreeing to the cancellation policy and the purchase payment policy.
Cancellation Policy: A full refund will be granted to cancellations made in writing on or before Friday, December
4, 2015. Name changes and substitutions are allowed at no fee. Regrettably, no refunds will be given on cancellations received on or after Saturday, December 5, 2015. Phone cancellations will not be accepted. Written cancellations must be sent by email to registration@atia.org
or faxed to +1 847-277-7414.
Purchase Order Payment Policy: If your organization is required to submit a purchase order for payment, please send your Purchase Order document with all pages of this registration form. Registrations paid by
Purchase Order are subject to the Cancellation Policy. Purchase Order payments are due no later than 30 days after the completion of the conference, March 7, 2016. Payments received after March 7, 2016 will incur a $50 late payment administrative fee.
If any circumstances or event beyond the control of ATIA causes cancellation of all or any portion of the event,
ATIA agrees to refund any portion of the registration fee which ATIA is reimbursed by insurance or other third party and shall not be liable for any other refund or payment arising from the cancellation or for other liability or damages arising from the event.
Please Note: On occasion, an ATIA photographer may take photos of participants at ATIA Orlando 2015, or of people participating in conference functions or activities. Please be aware that these photos are for AT IA’s use
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only, and may appear in ATIA conference programs, brochures, newsletters, website and other publications and materials. Your attendance constitutes your permission and consent for this photography and subsequent usage.
ATIA may use personal identifiable
information collected, such as to help minimize any potential hotel attrition penalties for the association. By registering for the conference you consent to such use. If you have any questions or concerns please contact ATIA at registration@atia.org
.
___ Check here if you do NOT want to receive e-mails from ATIA Exhibitors and Members with details including special offers or other conference-related materials.
ATTENDEE PROFILE
1. Please indicate your attendee category
(select all that apply):
(A) Accessibility Professional
(A) I am the purchasing decision-maker
(B) I approve purchases
(C) I recommend/influence purchasing decisions (B) Advocate
(C) AT Dealer
(D) AT specialist
(E) Consultant
(D) I am not involved in purchasing decisions
3. How did you hear about this conference?
(A) ATIA Web site
(B) AT Vendor
(F) Consumer
(G) Education administrator
(H) Federal Government
(I) Hard of Hearing/Deaf specialist
(C) Conferences AOTA, ASHA, CSUN, CTG,
RESNA, Other
(please specify): ________________
(D) Direct mail brochure
(E) E-Mail
(J) K-12 educator
(K) Occupational therapist
(L) Parent
(M) Physical therapist
(F) Word-of-mouth
(G) Advanced Program
(H) Other (please specify): ___________________
4. Please select conference materials in any of
(N) Rehabilitation specialist
(O) Speech-language pathologist
(P) Special education director
(Q) University affiliate these alternate formats (Limited availability - must be requested by December 18, 2015)
Note: Printed copies of the Braille and Large
Print documents will be available at the
Accessible Services and Material Desk. Up-todate conference information will also be
(R) Vision specialist
(S) Other (please specify)
2. Please indicate what most closely describes your role in purchasing decisions in your organization: available on the mobile app.
(A) USB with accessible materials including electronic Braille files
(B) Braille Conference Guide
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(C) Braille Session Grid
(D) Tactile Exhibit Hall Floor Map/Exhibitor List
(E) Large Print Conference Guide
(F) Large Print Session Grid
(G) Sign interpreter
(H) Other (please specify):
______________________________________
5. Have you previously attended an ATIA
Conference?
Yes No
If yes, please indicate the number of years you have attended an ATIA Conference:
(A) 1 year
(B) 1-5 years
(C) More than 5 years
(D) More than 10 years
6. Please indicate your interest area(s) (select all that apply):
(A) AAC (Augmentative & Alternative
Communication)
(B) Accessibility
(C) Blind/Low Vision
(D) Deaf/Hard of Hearing
(E) Education/Learning
(F) Physical Access/Mobility
(G) Transition/Vocational
(H) Other (please specify)
___________________________________
7. Are you a member of RESNA? (Rehabilitation
Engineering and Assistive Technology Society of North America)
(A) Yes
(B) No
8. Are you a certified RESNA ATP? (Assistive
Technology Professional)
(A) Yes
(B) No
9. Are you attending the ATIA Annual
Conference to earn continuing education credits?
(A) Yes
(B) No
If yes, what type of continuing education credit applies to you? (Check All that Apply)
(A) AAC Institute
(B) ACVREP
(C) AOTA
(D) ASHA
(E) Other (Free Text Box)
10. If you have any special needs, accommodations or dietary requests, please detail your requirements below:
11. Are you interested in attending edcampAccess International at ATIA 2016? For more information about this program please visit: www.atia.org/conferene.
By selecting yes, your information will be shared with the organizers of the edcampAccess International unconference.
(A) Yes
(B) No
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