BEYOND THE BUZZWORDS: a BOOTCAMP FOR DISABILITY RIGHTS ADVOCATES              Application form
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.
Sign in to Google to save your progress. Learn more
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
Clear selection
help with costs associated with getting there
Clear selection
an accessible hotel room  (type your information in Other:):
Clear selection
attendant care
Clear selection
If yes, will you be bringing your own or do you need someone local?
Clear selection
ASL Interpreter
Clear selection
Real-time captioning
Clear selection
Materials in Braille or electronic format
Clear selection
special diet (type your details in Other:)
Clear selection
Other needs;
Would you be willing to share a hotel room?
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? *
3. Do you think you'd benefit from learning more? *
4. Would you consider yourself knowledgeable about laws that impact people with disabilities? *
5. Why do you want to participate in "Beyond the Buzzwords"? *
6. Have you had any experience in advocating or community organizing? *
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
Clear selection
Accessibility: explain why you chose this:
Community Support/Home Health Services
Clear selection
Community Support/Home Health Services: explain why you chose this:
Public Transportation
Clear selection
Public Transportation: explain why you chose this:
Accessible/Affordable Housing
Clear selection
Accessible/Affordable Housing: explain why you chose this:
Educational Issues
Clear selection
Educational Issues: explain why you chose this:
Better Employment Opportunities
Clear selection
Better Employment Opportunities: explain why you chose this:
Benefits (Medicaid, Social Security, etc)
Clear selection
Benefits: explain why you chose this:
More informed and pro-active elected officials
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
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy