Mayor’s Mental Health Task Force Monitoring Committee

Central Texas African American Family Support Conference

2010 CTAAFSC General Registration Now Closed

Registration is now closed. If you would like to attend the conference, please register on-site.

By checking this box, I certify I am 18 years of age or older.

Registrant Information

*First Name

*Last Name

Title

Organization

*Email Why do you need my email?

Phone (3 digit area code + 7 digit number)

Mailing Address

City

State

*Zip Code

*How many children under the age of 18 will you bring to the conference?
0 1 2 3 4 5

Please list name of each guest:

Conference Schedule

*What dates will you attend the conference?
Thursday Feb. 3 Friday Feb. 4 Both Days

*Is this your first time attending the CTAAFSC?
Yes No

How did you hear about the CTAAFSC?
Email Family or Friend Advertisement Newsletter Postcard Radio Website Other

If other, please describe below:

Lunch (Free to those who attend)

*What dates will you attend the luncheon?
Thursday Feb. 3 Friday Feb. 4 Both Days Not Attending

Do you have any special dietary needs?
None Low Sodium Vegetarian Other

If other, please describe below:

Special Accommodations

Please describe any special accomodations you require e.g. auxiliary aids, sign language interpreter services or materials in alternate format.

In registering for this CTAAFSC, you give Austin Travis County Integral Care (ATCIC) permission, in connection with any photographs taken during said Conference of yourself and any dependents accompanying you or in which you or they are included with others, the right to use and reuse, in any manner at all, photographs in whole or in part, either by themselves or in conjunction with other photographs, in any medium and for any purposes whatsoever, including without limitation, all promotional or publicity uses, and you release ATCIC from any and all claims, actions, and demands arising out of or in conjunction with the use of said photographs.

By checking this box, I have read and agree to the terms listed in this photography release.