If you have any questions or concerns, please call 219/769-5055 or write to 

For ASL users, if you prefer to fill out the application using ASL, please contact this videophone number: 219.232.1063.[0]=AZXLsTN_XmwF66FkqvlkL9PNaun4zNRUsYBK18GL-B2atgqxXm8lklwgbWLzBRPfWGV76xXNtusFDMUxx05r6CnLCHB_4j1Urw3X7tSiuFlMBQydGNGir9bmjo6Jv4uha-0CDRcOiOpGeZTRhigLRuuGVqrURhiCfR_9a4_0CXJnNOoS0BbA5YaDWYV8iUFPX8u7Ir6CG7TFbQ-Tdo0Jn-kM&__tn__=EH-y-R
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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
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help with costs associated with getting there
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an accessible hotel room  (type your information in Other:):
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attendant care
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If yes, will you be bringing your own or do you need someone local?
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ASL Interpreter
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Real-time captioning
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Materials in Braille or electronic format
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special diet (type your details in Other:)
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Other needs;
Would you be willing to share a hotel room?
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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:
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Accessibility: explain why you chose this:
Community Support/Home Health Services
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Community Support/Home Health Services: explain why you chose this:
Public Transportation
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Public Transportation: explain why you chose this:
Accessible/Affordable Housing
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Accessible/Affordable Housing: explain why you chose this:
Educational Issues
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Educational Issues: explain why you chose this:
Better Employment Opportunities
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Better Employment Opportunities: explain why you chose this:
Benefits (Medicaid, Social Security, etc)
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Benefits: explain why you chose this:
More informed and pro-active elected officials
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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.
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