AMERICAN COUNCIL OF THE BLIND OF TEXAS, INC.
309 PALOVERDE LANE FT. WORTH, TX 76112
CONFERENCE/Convention REGISTRATION FORM
PLEASE USE BLACK INK
First and Last Name:
Street Address:
City: State: Zip:
Phone: Cell phone:
E-Mail:
Are you an ACBT member? Yes: (Chapter) NO
Program Format: Lg. Print Braille Audio CD
Special medical/dietary needs, please specify:
Will you need an assistive listening device (ALD) for the general sessions? Yes No
Will you have a guide dog in attendance? Yes No
Check the Items of your choice:
$55.00 Conference/Convention Registration Fee - Includes all sessions, Exhibits, Saturday Luncheon, Saturday Evening Banquet, and Sunday Morning Awards Breakfast and business meeting. Registration Forms postmarked after 9/9/2016—and onsite registration $65.00
$10.00 Viewing of Exhibits, Workshops and
Sunday Morning Business Meeting only
DO NOT PAY if paying the above $55.
$17.00 Friday Morning Tour of the Bob Bullock Museum 9:30 AM - 12:30 pm.
Will you be using a wheelchair or scooter? Yes
If yes, can you transfer to a bus seat without assistance? Yes No
$5.00 Friday Evening Entertainment (cash bar available)
$10.00 - Guide Dog Users Breakfast for members of GDUTX
$21.00 - Guide Dog Users Breakfast for non-members of GDUTX
$12.00 T-Shirts (available in adult sizes only)
S M L XL 2X 3X 4X
$10.00 Walk For Success Entry Fee. Will you walk: Yes No
Please return all Walk related forms, except sponsor list, with
Registration form and your payment.
Will you attend the Leadership Forum on Friday, September
23rd at 2:30 pm? Yes
Will you attend the ACBT Open House for first time conference attendees and others seeking more information about ACBT?
Saturday, Sept. 24th at 2:45 pm Yes
ACBT INDIVIDUAL SPONSORSHIPS
Please enter dollar amount of sponsorship
$ Crystal $200 or more
$ Garnet $100--$199
$ Turquoise $50--$99
$ Emerald $25--$49
$ Medallion $1--$24
$Youth Advantage Program -- Please indicate amount of gift.
$ Total Amount Due for your selected items
NO REFUNDS
Please make your check for all selected items payable to:
“ACBT Conference” and mail along with your registration form in the envelope provided to:
Sheila Derrick, ACBT Treasurer
309 Paloverde Lane
Fort Worth, Texas 76112-1122