Florida Department of Education

Office of Equity and Access

Florida College Access Network (FCAN) Conference

April 6 – 8, 2005

St. Petersburg, Florida

Registration Form

Name, Title and Address of Registrant: ________________________________________

Telephone ______________________ E-mail ______________________________________

( ) Federal Agency

( ) State Agency

( ) Federal Program

( ) State Program

( ) Community Program

( ) Faith-Based Program

( ) Middle School

( ) High School

( ) Scholarship Program

( ) Tutoring/Mentoring

( ) Early Awareness/Access

( ) Other (explain): __________________________________________________________

You may reserve hotel accommodations at the Hilton St. Petersburg by calling 727-894-5000 or

the national Hilton reservations at 800-445-8667. Identify yourself as an FCAN Conference

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