MPower Me Workshop Registration Form
Use this form to register a Student to attend a free MPower Me workshop at The Arc of Northern Virginia.
Email address *
Student First and Last Name *
Your answer
What does Student like to be called? *
Your answer
Who is registering this Student? Please provide your name, relationship to Student, and your email.
Your answer
Who does the Student authorize to receive MPower Me communications, and how? Please provide name, relationship, and preferred contact information.
Your answer
Will any family members also attend the Workshop? *
Required
Please describe Student's current use of technology.
Please help us estimate Student's current level of self-determination. *
Required
MPower Me workshops offer opportunities to interact with peers and learn about improving independence. Which of the following would engage your Student the most?
Please describe your priorities or expectations for your Student's participation in the MPower Me workshop.
Your answer
Does your Student have any specific interests they like to talk about?
Your answer
Are there any sensitive subjects that upset the Student that you would like us to avoid if possible?
Your answer
Do you have any questions or comments for MPower Me at this time?
Your answer
A copy of your responses will be emailed to the address you provided.
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