Registration Closed - The Republic of Inclusion

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

June 27 - 29, 2017
Shenman Arts Centre Richcraft Theatre,
245 Centrum Blvd., Ottawa

Registration has now closed, unless you have been personally invited to register beyond the closing.

Full details of the Republic of Inclusion events are available online at https://nac-cna.ca/inclusion

Livestream of events on June 28, 2017 will be available between 10:00 - 12:30 Eastern and 14:00- 16:30 Eastern.

Clayton Baraniuk, Producing Coordinator, English Theatre, National Arts Centre
613-947-7000, extension 386 | clayton.baraniuk@nac-cna.ca

First Name

Last Name

Street Address

City

Province / State

Country

Postal Code / ZIP

Phone Number

Email Address

I am a Personal Support Worker for:

I prefer to be contacted by:

Phone

Skype / Glide with Signed Interpretation

Through a Personal Support Worker or Caregiver

Personal Support Worker Name:

Personal Support Worker Email:

Personal Support Worker Phone Number:

Please tell us how you participate.

To get around, I use (check any that apply):

Feet

A wheelchair or scooter

Crutches

Other:

To participate, I require (check any that apply):

General Admittance at the Event

ASL Interpretation

Audio Description

Captioning

A Listening Assist Device

A Personal Support Worker

Medical Equipment

A Support Animal

A Private Space, available during the events

Clear, detailed information in advance

The ability to make noise or movement

Other:

I have (check any that apply):

No allergies, sensitivities or dietary restrictions

Food Sensitivites

Allergies

Celiac Disease

Dietary Restrictions

Scent or Chemical Sensitivities

Light Sensitivities

Sound Sensitivities

Temperature Sensitivities

Sensitivity to touch (prefer limited physical contact)

Anxiety

Other:

Please list/describe your dietary requirements or restrictions (eg. Gluten Free, Vegan, specific food allergies, low sodium or sugar, etc).

Please list/describe any allergies or sensitivities we should be aware of (airborne, chemical, scent, textiles, fabrics, or anything else).

For Accommodations (Hotel Rooms) I would like: (check any that apply)

I do not require accommodations

A single room

A room to share (I have a roommate)

A room to share (I don't have a roommate)

Grab Bars in the bathroom.

Access to a roll in shower

Elevator access

A Pet Friendly room

Access to refridgeration

Private Accommodations (whole place, not a hotel)

Private Accommodations (a room in a house, not a hotel)

Parking

Other:

General Information (check any that apply)

I will be driving into Ottawa, and am open to ride-sharing

I am looking for a ride-share is possible

I live in Ottawa and could put someone up at my place.

I have a vehicle and could offer rides to the events.

I will have a Personal Support Worker, attendant or caregiver with me at the events.

I will provide my own food at all events.

Other:

Registration Fee: $50.00

Registration fees are non-refundable, and are spent providing food and refreshments at all events, as well as providing access supports for all participants. Personal Support Workers (PSW) who will not participate in shared meals do not need to pay the registration fees. If your PSW would like to participate in shared meals, please have them complete a separate registration form.

I will pay by: (Check One)

Please Note: If you are representing one of the partner organizations, please select Other and include the organizations name.

Credit Card (Visa, MasterCard, Amex)

Cheque

E-Transfer

Cash

I am unable to afford the registration fee but would still like to participate.

Other:

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms