Title:

First name*:

Last name*:

Address:

Country:

Phone:

e-mail*:

Participant characteristic (please check the most relevant)

AAC user

family member of AAC user

AAC user assistant

teacher

therapist

vocational therapist

psychologist

other professional

researcher

school administrator

student

producer/distributor of AAC equipment, software, materials

other

Work/Education

Institution:

Address:

I use a wheelchair (electric, manual): Yes No

I have a guide dog: Yes No

I have other needs: Yes No
Please specify:

I am AAC user

I am assistant to AAC user.

I am member of AAC user family.

None of the above.

(only one person per AAC user is entitled to lower conference fee) - please enter assistant's name:

I will take part in the entire Conference.

I want to take part on the second day of AAC equipment exhibition only (July 1st, 2011).

I want to participate in the special event - dinner in Belvedere Restaurant on July 1st, 2011.

I want to participate in the Warsaw guided tour on the third day of the conference (July 2nd, 2011, about 15.15) (a fee of 50 złoty will be collected during the Conference).

Total fee:

There are two methods of payment:

1. Credit Card: charged during electronic registration.
   Settlement of credit cards and electronic transfers is carried out by Dotpay Settlement Centre
2. Bank transfer:
   • Beneficiary: Stowarzyszenie na rzecz Propagowania Wspomagających Sposobów Porozumiewania się “Mówić bez Słów”
   • Address: ul. Białobrzeska 44, 02-325 Warszawa
   • Account number: 54 2490 0005 0000 4600 2501 1001
   • SWIFT: ALBPPLPW
   • IBAN: PL 54 2490 0005 0000 4600 2501 1001
   Transfer message: „AAC in Europe” and the full name of the registrant
   Note: If the fee has not arrived in the Conference bank account within 7 days, the registration process will be cancelled and you will need to re-register. Please pay promptly!

Name of the institution to be invoiced:

Address:

Postal Code and City:

Country:

VAT number: