Planning a Life Conference 2023 Participant Form

I am registering for the following 2023 PAL session:

Our Planning A Life conferences will be held on a Friday and a Saturday. On Fridays, presentations for parents and professionals will be virtual. On Saturdays, PAL for parents, professionals, and a separate program for youth with disabilities will be in-person. Your Zoom link will be listed in your confirmation email. The location address for in-person event is listed on the website.

First Name(Required)

Last Name(Required)

Email(Required)

Home Address/Street and Number(Required)

City/Town(Required)

State(Required)

Zip Code

Primary Language(Required)

Other language(s) (optional)

To which gender do you identify as? (optional)

What is your ethnicity?

What is the ethnicity of your child/youth with special needs?

What is your race?

If applicable, what is the race of your child with special needs?

What is your total household income?

What is the highest level of education that you have completed?

Age of your child with disabilities?

How many family members are in your household?

Will you need any accommodations to participate in Planning A Life?

If you are registering as a parent/caregiver, will your youth/young adult be attending our in-person session for youth/young adults on Saturday (no charge)?(Required)

Youth Information

Child's/Young adult's First Name(Required)

Child's/Young adult's Last Name(Required)

Youth's date of birth(Required)

Please enter the name of youth participant’s educational program(Required)

Please tell us about the youth participant and how we can best support her/him/them during the activities.(Required)

Is there anything else you’d like us to know about you or your child/young adult?

Payment:

Please contact us (businessoffice@fcsn.org) if paying by company purchase order.

Total Registration Fee:(Required)

*Youth are free to attend on Saturday when selecting 1 Family Member/Caregiver or 2 Family Members/Caregivers

Second Family Member's First Name

Second Family Member's Last Name

Second Family Member's Email Address

Coupon

Total

Credit Card Information:(Required)

Please enter information exactly as it appears on your Credit Card statement

Card Details

Cardholder Name

Billing Address: (Please enter billing information exactly as it appears on your Credit Card statement)(Required)

Full Name

Email(Required)

Hidden

Payment Title

PAL 2023 Conference

Planning A Life Conference Fall 2023

Youth Information

Payment:

Your Support
Moves Dreams
Forward

Planning a Life Conference 2023 Participant Form

Planning A Life Conference Fall 2023

Youth Information

Payment:

Your Support Moves Dreams Forward

Your Support
Moves Dreams
Forward