Empowering Minds and Enriching Futures
~Mental Wellness and Disability~

First/Last Name *

Phone Number *

Email *

Mailing Address *

City, State, Zip *

What is your relation to Spina Bifida *

Individual living with Spina Bifida

Parent/Caregiver

Extended family member/friend

Provider

Other

Name/Ages of each person in your registration party *

The registration fee is $15 per person. I understand that anyone in my registration party who is 13 years or younger may attend for free, and I am responsible for payment before the start of conference. *

Yes

I understand that I am responsible for paying the below designated registration fee before start of conference: *

Number of individuals aged 13 or older x $15 = registration fee. (Example: 2 people x $15 = $30 registration fee)

Please list any dietary restrictions or allergies you or someone in your party may have:

SBANYS has a hotel block for $159/night at the DoubleTree by Hilton Hotel Syracuse. Will you be staying the night and need a room from our block? *

To be a part of SBANYS room block, you must register for the conference by June 1st. Any booking through this venue MUST be done by SBANYS.

Yes, just Friday, July 25th

Yes, just Saturday, July 26th

Both Friday and Saturday

No

SBANYS will reimburse travel and lodge expenses for any individual living with Spina Bifida who lives more than 60 miles away.

If you need financial or transportation assistance, please email: Kathleen.Watt@sbanys.org
Any bookings at this venue must be done by SBANYS regardless of reimbursement eligibility.

Photo and Liability Waiver Release *

By registering for this conference you and anyone in your registration party acknowledge that SBANYS has full permission to use photos, videos, film or any other record of this event in which you may appear for a legitimate purpose. You also agree to indemnify and hold harmless SBANYS to all costs expense, and liability arising out of you or your child’s participation in this event. You do hereby waive all claims for damage or loss to you or your child’s person or property which may be caused by an act, by SBANYS, its officers, agents or employers arising directly or indirectly from my or my child’s participation in this event.

Yes

I am interested in attending or hearing more information about the following SBANYS weekend events in Syracuse

Syracuse Mets Game: Friday, July 25

On the Trails Accessible Recreation: Saturday, July 26th

Transportation Summit: Sunday, July 27th

Comments or Questions

SBANYS Conference

Empowering Minds and Enriching Futures ~Mental Wellness and Disability~

SBANYS will reimburse travel and lodge expenses for any individual living with Spina Bifida who lives more than 60 miles away.

If you need financial or transportation assistance, please email: Kathleen.Watt@sbanys.org Any bookings at this venue must be done by SBANYS regardless of reimbursement eligibility.

Empowering Minds and Enriching Futures
~Mental Wellness and Disability~

If you need financial or transportation assistance, please email: Kathleen.Watt@sbanys.org
Any bookings at this venue must be done by SBANYS regardless of reimbursement eligibility.