ImpAACt Voices | Registration and Release Form (AAC users 14 and older)
This form must be completed and signed by the attendee if they are 18 years or older and can legally provide consent. 
If the person wanting to attend is under 18 or has a legal guardian, a parent or legal guardian must complete and sign the form. 
  
This form registers you for ImpAACt Voices AAC Hangouts and programs. Your responses help us to improve our programs and ensure all voices are heard. It includes a media release section for photos and videos. It takes about 5-10 minutes to complete.

Need assistance completing this form? Email info@impaactvoices.org.

Hangout details are sent the week before the next Hangout after you register.


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I am completing this form as the: *
First name of AAC user (14 and older) *
Last name of AAC user (14 and older) *
eMail address of AAC user
(We'll use this to send event emails.)
If they do not have an email, enter N/A. Event emails will be sent to the parent or legal guardian's email instead. You may list more than one email address.
Parent or Legal Guardian Information (if applicable):
If you are the AAC user completing this form, please enter “N/A” for the next three questions.
First name of parent or legal guardian (if applicable):
If not applicable, enter N/A.
 *
Last name of parent or legal guardian (if applicable):
If not applicable, enter N/A.
 *
eMail address of parent or legal guardian (if applicable):
If not applicable, enter N/A.
 *
Address of AAC user 
(Needed for grant reporting and kept confidential.)
City of Residence of AAC user
(Needed for grant reporting and kept confidential.)
 *
State/Province of AAC user
(Needed for grant reporting and kept confidential.)
 *
Zip code of AAC user
(Needed for grant reporting and kept confidential.)
 *
AAC user’s date of birth (mm/dd/yyyy, Hangouts open to ages 14+) *
Age Confirmation  *
Diagnosis (optional): 
If you're comfortable sharing, list any relevant diagnosis. This helps us for grant requirments. You may enter "Prefer not to say" if you'd rather not share and kept confidential. 
 *
Types of AAC used:
Please list all forms that are currently used (e.g., speech-generating device, sign language, gestures, typing, etc.).
 *
Will the main form of AAC have voice output?  *
If so, will voice output be used during Hangouts?  *
How would you describe your experience using your AAC device? 
(Choose the ooption that best describes you right now.)
 *
Share a little bit about yourself (AAC user). What are your favorite hobbies or activities? *
Are there topics you would like to have discussed?  *
What do you hope to gain by attending our programs? *
Do you currently know other AAC users? *
Which Hangouts do you plan to attend? (Select all that apply.) *
Required
We use Zoom® for our virtual Hangouts. 
Let us know if you need any accommodations or support to improve your experience.
 *
Would you like information on how to configure your Zoom® settings so that the Zoom® Host can mute and unmute you if needed? 
This can be useful if there's background noise during the Hangout. 
 *
What Zoom® username will you use? This helps our Zoom® host recognize you and keep the platform secure.  *
Would you like a 15-minute appointment by Zoom® or phone call with a volunteer to answer your questions? *
How did you hear about us? *
Who introduced you to ImpAACt Voices? We'd love to thank them. *
This release authorizes ImpAACt Voices to take, share, reproduce, and distribute photos, videos and personal identifiable information of myself, my child, conservatee, ward on ImpAACt Voices' website, social media platforms, eNewsletter and other materials supporting the AAC and ImpAACt Voices community. All photos and videos taken are the property of ImpAACt Voices and you may revoke this authorization at any time.
Select one option below.
 *
By entering your first and last name below you are submitting your signature for the authorization of photos, videos and personal identifiable information of you as indicated in your above answer and have read and fully understand the term of this release. 

I understand that I may revoke this authorization at any time by providing written notice to ImpAACt Voices at info@impaactvoices.org. However, such revocation shall not affect ImpAACt Voices' right to use information, photos /videos made or obtained prior to my revocation of this authorization.

Signature of Individual Releasing Information, Parent, Legal Guardian or Conservator required.
 *
By entering your first and last name below you are submitting your signature for the authorization of the above attendee to attend ImpAACt Voices Hangouts and programs. 

Signature of Individual Releasing Information, Parent, Legal Guardian or Conservator required.
 *
Please CLICK HERE to read the AAC Hangout Guidelines & Etiquette form. Once you have done so, please return to this form and sign below. 

By entering your first and last name below, you are submitting your signature and agreeing that you received, understand, and agree to follow the AAC Hangout Guidelines & Etiquette form. 

Signature of Individual Releasing Information, Parent, Legal Guardian or Conservator required.
 *
Would you like to be added to our email list?  *
How can we support or improve your experience?
(You can share support requests, accommodations, topic ideas, or anything else on your mind.) We'd love to hear from you.
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