Register for the RAISE Summit for RSA PTIs!

Please complete the following information regarding your participation at the RAISE Summit starting May 1st and ending May 3rd, 2016. The National Resources for Access, Information, Self-determination, and Employment Technical Assistance Center will arrange and cover the cost of travel and single room hotel accommodations for one person from each RSA-PTI Center. There is no cost for Summit registration for additional participants. However, their center must pay for their travel and accommodations. Also, if you are planning to attend the NTACT Capacity Building Institute on May 3-5, you must register at: http://uncc.surveyshare.com/s/AYA6E4B

First Name*

Last Name*

Parent Center Name*

Your E-mail address:*

Office Phone:*

Mobile Phone:*

What 3 takeaways do you hope to get at the Summit?

Please let us know what information and/or skills you hope to gain during your time with RAISE and your RSA-PTI colleagues.

Would you like RAISE to cover your travel?*

Note: The RAISE Center will cover travel and accommodations for only ONE RSA-PTI representative.

Select or enter value

Please let us know your travel plans.

If your travel costs will be covered by RAISE, you will receive further instructions on making flight arrangements, when you submit this information.

Your Date of Arrival?

Your Departure Date

Any Special Accommodations/Dietary restrictions?

Please list any special accommodations or dietary restrictions here.

Are you also planning to attend NTACT Institute?*

Yes, I have registered

Yes, I have not registered yet

Undecided

For further information or assistance:

Please contact Maria Rodriguez, mrodriguez@spannj.org, 862-214-2813

Send me a copy of my responses

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