Registration Form
Please complete this form and print, fax, or mail to:
National Center on Accessibility
501 North Morton St., Suite 109
Bloomington, IN 47404-3732
Fax: (812) 856-4480
Course:

Accessibility Coordinator Training: Accessibility Management for Parks and Recreation - Bloomington, Indiana - May 14-17, 2007
Name:
Title:
Park/Facility:
Agency:
Street Address 1:
Street Address 2:
City/State/Zip: City: State: Zip:
Email:
Phone/Fax: Phone: Fax:
Credit Card #:
Expiration Date: Month: Year: Card Type:
Name on Card:
Signature:
Paying for this course by Purchase Order Number:

Have you ever previously attended a NCA training course? Yes: No:

      Previous training course location:
      Date of previous training course:  

Please indicate if you require any of the following accommodations:

» A sign language interpreter? Yes:
» Written materials available in alternative formats? Yes:
Please indicate your preference: Braile? Large Print? Audio Cassette?
Computer Disk
» Wheelchair accessible transportation to and from NCA program site visits?
» An Assistive Listening Device?
In the box below please indicate if you require any other similar accommodations that are not
listed above:
If you indicated that you require any accommodation, a representative from the National Center on Accessibility will contact you to ensure you receive the most effective means of accommodation.