Registration Form / Formulario de Inscripción

Number of Attendees / Número de Asistentes: First Name / Nombre: Last Name / Apellido: Email / Correo electrónico: Day Phone / Teléfono: Address / Dirección: City / Ciudad: State / Estado: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavat Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip / Código postal: - County / Condado: Role / Rol primario: Parent/Family Member | Padre/Miembro de Familia: Foster Care Provider | Proveedor/a de Foster Care Individual w/Disability | Persona con Discapacidad Youth w/disability | Joven con Discapacidad Agency | Agencia Brokerage County Developmental Disability Staff | Personal del Departamento de Discapacidad del Desarrollo Educator | Educador Service Provider | Proveedor de Servicios Other | Otro FACT Supporter | Seguidor de FACT Friend | Amigo Year of Birth of Person with Disability / Año de nacimiento de la persona con discapacidad Disabilities/Diagnosis / Diagnóstico de discapacidad ADD/ADHD Autism Spectrum Disorders Blind/Visual Impairment Cerebral Palsy Communcation Disorders/Speech and Language Impairments Deaf - Blind Deaf - Hearing Impairment Developmental Disabilities Down Syndrome Dyslexia Emotional - Behavioral Disabilities Fetal Alcohol Syndrome/Effects Fragile X Syndrome Intellectual Disability Learning Disabilities Medical Conditions/Special Health Needs Mental Health Conditions Physical Disabilities Post Traumatic Stress Disorder Rare Disorders Rett Syndrome Seizure Disorder/Epilepsy Sensory Processing Disorder Tourette Syndrome Traumatic Brain Injury Unknown or Not Provided Primary School Eligibility / Elegibilidad para Educación Especial (IEP) ADD/ADHD Autism Spectrum Disorder Communication Disorder / Speech or Language Impairment Deaf-Blindness Deafness Emotional Disturbance Hearing Impairment Intellectual Disability Multiple Disabilities Orthopedic Impairment (physical) Specific Learning Disability Other Health Impairment (OHI) Traumatic Brain Injury Developmental Delay (Early Childhood) Visual Impairment including Blindness Gifted Prefer not to Disclose Unknown No Special Education Eligibility School District / Distrito escolar Adel Adrian Albany Alsea Amity Annex Arlington Arock Ashland Ashwood Astoria Athena-Weston Baker Bandon Banks Beaverton Bend-La Pine Bethel Blachly Black Butte Burnt River Brookings-Harbor Butte Falls Camas Valley Canby Cascade Centennial Central Central Curry Central Linn Central Point Clatskanie Colton Condon Coos Bay Coquille Corbett Corvallis Cove Creswell Crook County Crow-Applegate Culver Dallas David Douglas Days Creek Dayton Dayville Diamond Double O Drewsey Dufur Public Schools Eagle Point Echo Elgin Elkton Enterprise Estacada Eugene Falls City Fern Ridge Forest Grove Fossil Frenchglen Gaston Gervais Gladstone Glendale Glide Grants Pass Greater Albany Gresham-Barlow Harper Harney County Harrisburg Helix Hermiston Hillsboro Hood River County Huntington Imbler Ione Jefferson 14J (Marion Co) Jefferson County 509J (Jefferson Co) Jewell John Day Jordan Valley Joseph Junction City Juntura Klamath County Klamath Falls City Schools Knappa La Grande Lake County Lake Oswego Lebanon Community Schools Lincoln County Schools Long Creek Lowell Mapleton Marcola McDermitt McKenzie McMinnville Medford Milton-Freewater Mitchell Molalla River Monroe Monument Morrow Mt Angel Myrtle Point Nampa Neah-Kah-Nie Nestucca Valley Newberg North Bend North Clackamas North Douglas North Lake North Marion North Powder North Santiam North Wasco County Nyssa Oakland Oakridge Ontario Oregon City Oregon Trail Paisley Parkrose Pendleton Perrydale Philomath Phoenix-Talent Pilot Rock Pine Creek Pine Eagle Pinehurst Pleasant Hill Plush Port Orford-Langlois Portland Powers Prairie City Prospect Rainier Redmond Reedsport Reynolds Riddle Riverdale Rogue River Roseburg Public Schools South Coast Education Service District Salem-Keizer Santiam Canyon Scappoose Scio Seaside Sheridan Sherman Sherwood Silver Falls Sisters Siuslaw South Harney South Lane South Umpqua South Wasco County Spray Springfield St Helens St Paul Stanfield Suntex Sutherlin Sweet Home Three Rivers/Josephine CU Tigard-Tualatin Tillamook Troy Ukiah Umatilla Union Vale Vernonia Wallowa Warrenton-Hammond West Linn-Wilsonville Willamina Winston-Dillard Woodburn Yamhill-Carlton Yoncalla Recipient Of / Recibe Primary Language / Primer Idioma Arabic Chinese-Cantonese Chinese-Mandarin Duala English Fanti Hindi Japanese Korean Marshallese Romanian Russian Serbo-Croatian/Bosnian Somali Spanish Tagalog Vietnamese Other If you have a coupon, please enter code here (case-sensitive):