The Maine Developmental Disabilities Council

First Name:   Last Name:

Organization/Agency Affiliation:

Street Address:

City/Town: State: Zip:

Email:

Daytime phone:

Accommodation requests must be made by November 25, 2009 to ensure availability.

I require a sign language interpreter:  Yes   No

Please describe any other accommodation requests, including special dietary requirements:
 

Conference Fee (includes lunch):

$25 per person and $15 each for additional family members.

 Total amount: $

Name of 2nd family member attending:

Name of 3rd family member attending:

I would like to apply for a scholarship (please complete Scholarship Application below).

Method of Payment:

Please select your method of payment, made payable to Maine Developmental Disabilities Council, below. Sorry, we can not accept credit card payment.

Check       Purchase Order - P.O. #

Scholarship Application:

Deadline to apply for a scholarship  is Monday, November 16, 2009.

Monthly Income after taxes: $  Number in household:

I request (check as many as apply):

Tuition waiver

Mileage reimbursement

Overnight accommodations

Is there anything special you would like us to know when considering your application?

Please mail check or purchase order, payable to Maine Developmental Disabilities Council, to:

University of Maine
Center for Community Inclusion & Disability Studies
Attention: Susan Russell
5717 Corbett Hall, Room 114
Orono, ME 04469-5717