Contact Name *

First Name

Last Name

Phone

(###)

###

####

What LifeCourse Domain describes your organization?

Choose the best, even if there is more than one.

Advocacy & Engagement: Choosing how to live your life, making choices & goals, speaking up

Community Living: Where and how someone lives

Daily Life & Employment: What a person does as part of every day life

Healthy Living: Managing & accesing health care

Safety & Security: Staying safe from abuse; financial & legal rights & issues

Social & Spirituality: Having friendships, relationships, exploring faith & spirituality

Table Preferred (choose one)

6 foot rectangle

8 foot rectangle

Electricity (limited availability, first come basis)

Yes

No

Exhibitor Fee *

Your fee helps cover the cost of the venue.

$25

$50

Invoice

Check here if you need an invoice billed to you.