MUHSEN MAS ICNA 2021 Special Accommodations Registration
2301 South King Drive
Chicago, IL 60616
Sunday, December 26th-Tuesday, December 28th
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Name of Family Member with Disability, First and Last (if different than person completing form)
Age of Individual with disability
Name of Person Completing Form
Email Address where you can be contacted
Phone number where you can be contacted
Please list below/specify Disability
Supports Needed at Convention
Please check all that apply
Special Needs Child Care
One on One Aide (Assistance getting from Session to Session)
Access to Quiet Room
Sign Language Interpretation
Wheelchair Rental Information
Can the individual with Special Needs wear a mask?
Allergies of Individual with Special Needs
Is the individual with Special Needs vaccinated?
Please note any additional questions or comments below
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