MUHSEN MAS ICNA 2021 Special Accommodations Registration
WEBSITE: www.muhsen.org
EMAIL: info@muhsen.org

CONVENTION LOCATION:
McCormick Place
2301 South King Drive
Chicago, IL 60616

mascon.org
CONVENTION DATES:
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
Required
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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