Registration 2021 PCB Conference & Convention “Strengthening Community Through Unity” a Virtual Event September 16-19, 2021 2021 PCB Conference and Convention Registration Form "Strengthening Community through Unity"September 16-19, 2021 We encourage you to register by September 3 to allow enough time for postal delivery of your accessibly formatted program book. If your registration is received in the office after the 3rd, your program book will only be available electronically, either in Word via email or in Daisy audio download from our website. Full Name:* Address:* City:* State:* Zip Code:* E-mail: Phone (please include area code):* Requested format of your Conference ProgramBrailleLarge PrintEmailAudio/Thumb Drive Do you have a long distance calling plan?YesNo Do you need the toll-free number to call into the conference?YesNoConnecting to the Conference:When using a land-line phone, Zoom is a toll call unless you have an unlimited long-distance calling plan. Referred by a friend: Were you encouraged to attend the conference by a PCB member?*YesNo If someone did refer you, please name the person.Conference Activities:Please indicate how you would like to participate. Descriptions of each event are available on the preliminary schedule.Thursday, September 16, 2021 9:00 PM Jeopardy for the Common Man, Woman & Non-Binary Person (Six contestants)*I would like to be a contestantI will enjoy from the audienceI will not attendFriday, September 17, 2021 9:30 AM Self-Advocacy Workshop*I will attendI do not plan to attend 12:00 PM Welcome to the PCB Community: If you are new to PCB or the PCB Conference, join the Peer Engagement Team to learn more about PCB while we get to know you a little better too.*I am a first time conference attendee and will participateI have attended other PCB conferences and want to participate in fellowshipI do not plan to attend this event 9:00 PM Two Truths and a Tall Tale:*I would like to be a contestantI would like to be an inquisitorI will participate from the audienceI will not attendSaturday, September 18, 20211:00 PM PCB Business MeetingOnly paid 2021 PCB members who are registered for the conference may attend this event. All who expect to vote should be sure to join the meeting as an individual to retain their individual PCB vote. Since we will use Zoom's hand-raising function, married couples, those using three-way calling, and others who typically share a connection should plan for accessing through their own device. Will you need toll-free calling service to access the business meeting?*YesNo 8:00 PM Saturday Night Open-Mic: This is an opportunity to share your talents, passions, and interests with our PCB community in a safe space. Consider what you might share, a story, song, poem, tongue twister, brain teaser, instrumental, comedy, impersonation, essay, etc. Participants will be given up to five minutes.*I will prepare to share (please answer next question as well)I will support from the audienceI will not attend If sharing, please indicate what you intend to share:Sunday, September 19, 2021 3:00 PM PCB Live Auction Toll-free calling service is not being offered for this fundraiser event. We will do our best to match those without Zoom access with a peer phone partner who does have access. Please indicate your situation for the auction.*I do not have access to Zoom and would need to be brought into the auction.I have Zoom access and can bring someone else into the auction.I will not attend.I will attend on my own. Conference Mentor: We'd like to match those new to the conference or using Zoom with peers who have more experience and can provide support to make sure everyone has a great conference experience. Indicate if you would like to participate.*I would like a conference mentor to guide meI want to be a conference mentor to provide support.I do not wish to participate in this endeavor. Optional Demographic Information: Please check all that apply to you.I have a vision-related disability.I have a hearing-related disability.I have a physical disability.I have a learning-related disability.I do not have a disability. Would you like to purchase any 50/50 tickets to support our Room Rate Fund to subsidize the overnight rate for our next in-person conference? Tickets are $5.00 each? Please select "yes" and enter how many you would like to purchase.Yes, I want to purchase 50/50 ticketsQuantity Please consider contributing to support this year's conference. Anyone who donates at least $5 can give a community shout out in the conference program.Patron ($5)Contributor ($10)Benefactor ($25)Other Contribution Amount Other Contribution Amount: USD Complimentary Community Shout-Out: If you are contributing at least $5.00 in support of the conference, please include an upbeat shout-out to be published in the conference program. Must be 15 words or less. SAMPLE -- Congratulations! Joe and Jill Blink celebrating 25 years together! We love you J&J! - Their ChapterSAMPLE -- Going blind opened my eyes to the real beauty in people. Thanks for supporting me. - Justin Tyme Your Shout-Out: Total Payment Due:To pay online by PayPal or credit card click submit.Note: This will take you in to the PayPal screen. If you don't have PayPal, click “Guest Checkout” to enter your email address and begin the process to pay by credit or debit card. Once you submit your payment information, it will give you an opportunity to sign up for PayPal. You’ll need to click the “Not Now” button to process your payment confirmation.SubmitResetTo pay via check or money order, please click submit and then send payment to: Pennsylvania Council of the Blind, PO Box 68, Volant, PA 16156.You may also pay by calling our office at 877-617-7407.