EmpowerNL Disability Services Membership Form
MISSION STATEMENT

Empower provides supports, resources, and opportunity for people with disabilities, to make informed choices about their lives.

Sign in to Google to save your progress. Learn more
Empower provides services to individuals with disabilities. Do you identify as having a Disability? *
Important note about Empower membership!
If you sign up to be an Empower member, you will become a general member (General Member will receive emails, Black Spruce newsletter, attend summer BBQ, AGM, Christmas Dinner & Dance, Volunteer event and International Day of Persons with Disabilities), to become an active member you need to attend 2 activities outside the above events (examples pottery night or clay café. Active members may receive discounts on events). To keep your active membership, you must attend 2 activities outside our general membership per year.
Would you like to be a General or Active Member?
Clear selection
Empower believes in being barrier-free to all people, please select what would make our events and activities more barrier-free for you. *
Required
Do you require accessible formats for activities or event (Chose One ) *
"Read Below  and Confirm Signature"
Please sign to confirm that you understand the below Mission Statement and Individual Support Person Role.

Mission Statement
Empower provides supports, resources, and opportunity for people with disabilities, to make informed choices about their lives.

Individual Support Person Role (This person is to support you during the event or activity. They ensure your safety in
case of an emergency.)
I _______________ ( Your Name) support the Empowers mission statement and understand Empowers individual support person role. *
Enter Your Name
Your Personal Information
Your information is not shared with any third party and is only used by Empower. You have full control of your information at Empower. (*Note Disability, Age, orientation, status and Gender are optional and is used for research)
Your Name: *
Todays Date *
MM
/
DD
/
YYYY
Disability (* Optional)
We use this for research and is not shared with any organization.
Age? (* Optional)
We use this for research and is not shared with any organization.
Do you identify as being Indigenous? (* Optional)
Clear selection
Do you identify as being? (2SLGBTQIA+)  Two Spirit, lesbian, gay, bisexual, transgender, queer, asexual and + (* Optional)
Clear selection
Do you identify as being BIPOC Black, Indigenous and People of Color? (* Optional)
Clear selection
Are you a Newcomer to Canada?
Clear selection
Gender? (* Optional)
We use this for research and is not shared with any organization.
How Would you like to be contacted? - (Phone Call, E-mail, Text) *
Phone Number:
Your E-Mail Address:
Your Mailing Address:
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Empower, The Disability Resource Centre.

Does this form look suspicious? Report