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Florida Department of Education
Office of Equity and Access
Florida College Access Network (FCAN) Conference
September 22-24, 2004
Orlando, Florida
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Registration Form
Name , Title , and Address of Registrant:
________________________________________
Registrants will be representing which type of agency/program? Check all that apply:
( ) Federal Agency
( ) State Agency
( ) Local Government Agency
( ) Federal Program
( ) State Program
( ) Local Government Program
( ) Community Program
( ) Faith-Based Program
( ) School-Based Program
( ) Middle School
( ) High School
( ) Postsecondary Institution
( ) Scholarship Program
( ) Tutoring/Mentoring
( ) Early Awareness/Access
( ) Other (explain): __________________________________________________________
For which nights will you need hotel accommodations?
?
September 21 ____
September 22 ____
September 23 ____
PERSONAL ASSISTANCE REQUEST
Services will be available to sensory impaired participants, if requested in advance. Please check
if you are requesting such service.
interpreter for hearing impaired
reader for vision impaired
If it is determined that no sensory impaired person plans to attend this meeting, the services will not
be supplied.
NOTE: if you have special needs of the hotel, please notify them at the time you make reservations.
Please enclose a check or purchase order for $50.00 for each registrant payable to the Florida
Education Foundation and send with the registration form to:
FCAN Conference
Office of Equity and Access
Room 1446, Turlington Building
325 West Gaines Street
Tallahassee, Florida 32399-0400