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Registration Form

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Contact Information

First Name:

Last Name:

Address:

City:

State:

Zip Code:

E-mail:

Phone:

Access Request
I need an ASL sign language interpreter.
I have a service animal.
I need parking for a high-top van.
I need an assistive listening device.
I require printed Conference materials in the following alternate format:
I have dietary restrictions/other requests (please explain).

Other requests (please explain)

Personal Care Assistance Application
NOTE: Limited services provided. Participants requiring substantial assistance are asked to secure their own personal care attendants.

Yes, a personal care assistant will accompany me to the conference.

Name of assistant

I am requesting personal assistance provided by the Indiana Civil Rights Commission. (Please explain).

Disclaimer

By submitting the registration form you understand the Indiana Civil Rights Commission will take photographs and video at the conference for use in publications, presentations, promotional literature, or in advertising. Your name and other personal information will be kept confidential. Parking information and directions will be sent to you via e-mail prior to the conference. If you have any further questions or concerns contact Brad Meadows at (317) 232-2651 or bmeadows@icrc.in.gov.