DAC Med Local Chapter Interest & Startup Form
Thank you for your interest in starting a DAC Med chapter at your institution! DAC Med (Disability Advocacy Coalition in Medicine) is a national coalition dedicated to supporting students, trainees, professionals, and faculty in health professions who live with disabilities, chronic illness, or neurodivergence—or who are passionate allies.

Starting a chapter means building community, increasing awareness, and advocating for disability inclusion and accessibility within healthcare education and practice. Please complete this form so we can support you. If you have any questions please feel free to to email: DACMed.national@gmail.com
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Full Name
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Email Address
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Phone Number (optional)
School Name
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School Program (MD, DO, PharmD, PT, OT, Nursing, Public Health, etc.)
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Expected Graduation Year
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Why are you interested in starting a DAC Med chapter at your school?
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What goals would you hope to achieve with your local chapter in the first year?
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Have you participated in disability advocacy or similar organizations before (Yes or No)? If yes, please describe:


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Are there other students interested in joining your chapter leadership or helping you get started? (Multiple Choice: Yes, No, Unsure) *
If yes, please list their names and programs (if known): *

Have you identified a faculty or staff advisor who may be willing to support your chapter?


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Is there an existing student organization at your school related to disability, accessibility, or inclusion?


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If yes, how would DAC Med be different or collaborate? (Paragraph) *
Does your school require official recognition or registration for student organizations? (Multiple Choice: Yes, No, Unsure) *
If yes, please describe the process or let us know how we can help: (Paragraph) *
Which types of activities are you most interested in organizing through DAC Med? (Checkboxes: Peer support/community building, Guest speakers/panel events, Workshops or trainings, Disability rights or DEI collaboration, Advocacy initiatives (local, institutional, national), Awareness campaigns, Research or academic discussions, Other (please describe)) *
Would you be interested in joining monthly DAC Med chapter leader meetings? (Multiple Choice: Yes, No, Maybe) *
Is there anything else you'd like us to know, or do you have any questions? (Paragraph)
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