Name(s):
Mailing Address:
E-mail address:
Phone: (daytime preferred) please include area code.
Fax: (if available)
School (if student):
Access:
I need wheelchair access I need an ASL interpreter I have other special needs (specify):
Number attending: 1 2
Fees:
$50 individual
$80 couple
$25 student
I'm registering on-line and am mailing my check to the OGLBTC. I understand that my registration will not be complete until you receive my check or money/order.
Enclosed is my check/money order for $ payable to "PFLAG"
I need a limited income scholarship
I am attending the conference and I would like to make an additional donation of $to support the conference's efforts to keep registration fees low.
I am not able to attend the conference but I would like to make a donation of $to support the organizer's efforts to keep registration fees low and to assist in the important work of the conference.
I'd like to join a group for a dutch treat post-conference dinner at Rico's at 5:30 ($25/person pay at the conference)
I'll bring flyers, information, programs, handouts, for a Share the Wealth Table
This web site does not have a secure server. You may either print and mail this form to the OGLBTC or submit this form using the "register me" button below. There is also the Adobe Acrobat pdf option (which enables you to print a smaller, more attractive form.
OGLBTC (M/C 369) Univ. o f Illiois at Chicago 1007 W Harrison 1180 BSB Chicago, IL 60607
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