Disability Champions Program Registration

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Join the Disability Champions Mentorship Network and work with a mentor. Connect one to one and through virtual engagement sessions, receive preparation for advocacy and leadership and become a part of a community network.

Name *

Date of birth *

YYYY

Address (include Zip Code) *

School *

Grade in School *

Race and Ethnicity

Disability: Use other and describe in your own words or see descriptions of a variety of categories of disability here: https://www.dodea.edu/dodeaCelebrates/upload/Disabilities_Defined_IDEA.pdf

Speech or Language Impairment

Other Health Impaired

Autism

Emotional Disturbance

Specific Learning Disability

BLIND OR VISUALLY IMPAIRED

Deafness

Hearing Impairment

Deaf-Blindness

Orthopedica Impairment

Intellectual Disability

Traumatic Brain Injury

Multiple Disabiltiies

Other:

Clear selection

Please share any additional information you would like us to know about your disability.

Do you have an IEP or 504 Plan?

IEP

504 Plan

Clear selection

Gender

Languages spoken *

Phone Number *

Mailing Address *

Parent Guardian *

Parent/Guardian email *

Parent/ Guardian Phone *

Parent/Guardian Address *

What type of communication works best for you? *

Phone

List any accommodations you might need

Are you willing to work with a mentor? *

yes

How do you think a mentor might be helpful to you? *

What would you like to see or have in a mentor? *

Please share additional comments or questions.

Submit

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