BEYOND THE BUZZWORDS: a BOOTCAMP FOR DISABILITY RIGHTS ADVOCATES Application form

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If you have any questions or concerns, please call 219/769-5055 or write to bootcamp@everybodycounts.org

For ASL users, if you prefer to fill out the application using ASL, please contact this videophone number: 219.232.1063.https://www.facebook.com/officialmbf/photos/a.575657359198522/5321071841323693/?__cft__[0]=AZXLsTN_XmwF66FkqvlkL9PNaun4zNRUsYBK18GL-B2atgqxXm8lklwgbWLzBRPfWGV76xXNtusFDMUxx05r6CnLCHB_4j1Urw3X7tSiuFlMBQydGNGir9bmjo6Jv4uha-0CDRcOiOpGeZTRhigLRuuGVqrURhiCfR_9a4_0CXJnNOoS0BbA5YaDWYV8iUFPX8u7Ir6CG7TFbQ-Tdo0Jn-kM&__tn__=EH-y-R

You do not have to complete the whole application at one time. It will be automatically saved for up to two weeks. When you have finished, please hit the "send" button.

First Name: *

Last Name: *

Address/City/State/Zip: *

Phone Number: *

E-mail Address: *

How did you find out about "Beyond the Buzzwords"? *

Because we are hoping to include a broad representation of our disability community, we would appreciate it if you would provide the following information, but you do NOT have to do so if you don’t want to:

Your gender

Your age

Your race/ethnicity

What is your disability?

How long have you experienced this disability?

Would you require:

Help finding a way to get there

Yes

Clear selection

help with costs associated with getting there

Yes

Clear selection

an accessible hotel room (type your information in Other:):

Yes

Other:

Clear selection

attendant care

Yes

Clear selection

If yes, will you be bringing your own or do you need someone local?

bringing my own attendant

I would need someone locally.

Clear selection

ASL Interpreter

Yes

Clear selection

Real-time captioning

Yes

Clear selection

Materials in Braille or electronic format

Yes, Braille please

Yes, electronic format please

Clear selection

special diet (type your details in Other:)

Yes

Other:

Clear selection

Other needs;

Would you be willing to share a hotel room?

Yes

Maybe

Clear selection

Do you have any other concerns?

1. Why do you want to participate in this experience? *

2. How much do you know about people with disabilities other than your own? *

Quite a bit

some

not a lot

3. Do you think you'd benefit from learning more? *

4. Would you consider yourself knowledgeable about laws that impact people with disabilities? *

Very

Somewhat

Not really

5. Why do you want to participate in "Beyond the Buzzwords"? *

6. Have you had any experience in advocating or community organizing? *

Yes

If Yes, tell us about it. If no, why do you think that is? *

The following statements: Please check all the things you consider important to the Indiana disability community right now:

Accessibility

Yes

Clear selection

Accessibility: explain why you chose this:

Community Support/Home Health Services

Yes

Clear selection

Community Support/Home Health Services: explain why you chose this:

Public Transportation

Yes

Clear selection

Public Transportation: explain why you chose this:

Accessible/Affordable Housing

Yes

Clear selection

Accessible/Affordable Housing: explain why you chose this:

Educational Issues

Yes

Clear selection

Educational Issues: explain why you chose this:

Better Employment Opportunities

Yes

Clear selection

Better Employment Opportunities: explain why you chose this:

Benefits (Medicaid, Social Security, etc)

Yes

Clear selection

Benefits: explain why you chose this:

More informed and pro-active elected officials

Yes

Clear selection

More informed and pro-active elected officials: explain why you chose this:

What other issues concern you?

Explain why did you choose this?

Thank you.

Submit

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