Summit 2025 Registration Form

General Information

Legal Full Name

Preferred Name

What is the name of the individual applying?

Are you applying for yourself or someone else?

Primary Phone

Secondary Phone

Street address

Apt/Ste Number

City, State Zip code

Email

Birthday

Month

Day

Year

Care Coordinator

What Care Provider Agency are you with? If None, write N/A

Will you be travelling with a DSP/PCA or family member/guardian?

Do you require ADA accommodation or any sort of special accommodations

Emergency Contact name

Emegency Contact Phone

Gender

Ethnicity/Race?

Are you flying?

Have you attended a Peer Power Summit before?

Are you willing to share a room with another attendee?

Is there any other information that we should know about? Or that we should take into consideration? If none, write N/A.

Member$30

Regular Attendee$50

DISCLAIMER: This is an application fee not a registration fee. Sales are final.