Please fill out separate forms for each person.

 

Arizona Council of the Blind State Convention Enrollment
 
The DEC Nina Mason Pulliam Conference Center
5025 East Washington Street
Phoenix, AZ 85034
Friday, May 9, 2014
Check-in 8:00 a.m. Program 9:00 a.m.  5:00 p.m.

Your enrollment fee includes casual breakfast and box lunch. (Lunch may not be available for those enrolling after April 30th.)

 

Those fields marked with an asterisk (*) are required fields.

 

* First Name: 
* Last Name: 
* Address Line 1: 
Address Line 2: 
* City: 
* State: 
* Postal Code: 
* Phone Number: 
* Email Address: 
* AZCB Member Status: 
* Lunch Choice: 
If you have any dietary restrictions, please indicate them here: 
Identify any special need or accommodation you may require: