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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.
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First Name:
*
Your answer
Last Name:
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Your answer
Address/City/State/Zip:
*
Your answer
Phone Number:
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Your answer
E-mail Address:
*
Your answer
How did you find out about "Beyond the Buzzwords"?
*
Your answer
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 answer
Your age
Your answer
Your race/ethnicity
Your answer
What is your disability?
Your answer
How long have you experienced this disability?
Your answer
Would you require:
Help finding a way to get there
Yes
No
Clear selection
help with costs associated with getting there
Yes
No
Clear selection
an accessible hotel room (type your information in Other:):
Yes
No
Other:
Clear selection
attendant care
Yes
No
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
No
Clear selection
Real-time captioning
Yes
No
Clear selection
Materials in Braille or electronic format
Yes, Braille please
Yes, electronic format please
No
Clear selection
special diet (type your details in Other:)
Yes
No
Other:
Clear selection
Other needs;
Your answer
Would you be willing to share a hotel room?
Yes
No
Maybe
Clear selection
Do you have any other concerns?
Your answer
1. Why do you want to participate in this experience?
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Your answer
2. How much do you know about people with disabilities other than your own?
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Quite a bit
some
not a lot
3. Do you think you'd benefit from learning more?
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Your answer
4. Would you consider yourself knowledgeable about laws that impact people with disabilities?
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Very
Somewhat
Not really
5. Why do you want to participate in "Beyond the Buzzwords"?
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Your answer
6. Have you had any experience in advocating or community organizing?
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Yes
No
If Yes, tell us about it. If no, why do you think that is?
*
Your answer
The following statements: Please check all the things you consider important to the Indiana disability community right now:
Accessibility
Yes
No
Clear selection
Accessibility: explain why you chose this:
Your answer
Community Support/Home Health Services
Yes
No
Clear selection
Community Support/Home Health Services: explain why you chose this:
Your answer
Public Transportation
Yes
No
Clear selection
Public Transportation: explain why you chose this:
Your answer
Accessible/Affordable Housing
Yes
No
Clear selection
Accessible/Affordable Housing: explain why you chose this:
Your answer
Educational Issues
Yes
No
Clear selection
Educational Issues: explain why you chose this:
Your answer
Better Employment Opportunities
Yes
No
Clear selection
Better Employment Opportunities: explain why you chose this:
Your answer
Benefits (Medicaid, Social Security, etc)
Yes
No
Clear selection
Benefits: explain why you chose this:
Your answer
More informed and pro-active elected officials
Yes
No
Clear selection
More informed and pro-active elected officials: explain why you chose this:
Your answer
What other issues concern you?
Your answer
Explain why did you choose this?
Your answer
Thank you.
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