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.
Student First and Last Name
What does Student like to be called?
Who is registering this Student? Please provide your name, relationship to Student, and your email.
Who does the Student authorize to receive MPower Me communications, and how? Please provide name, relationship, and preferred contact information.
Will any family members also attend the Workshop?
Yes, a parent figure
Yes, a sibling or peer
I'm not sure yet
Please describe Student's current use of technology.
Advanced interest in everything related to technology
Mobile Technologies - phones, tablets, MP3 players
Computers - PC or Mac
Gaming systems - (e.g. Playstation, Xbox, Wii)
TV - streaming videos or music (e.g. Netflix, YouTube)
Please help us estimate Student's current level of self-determination.
Able to self-advocate - can clearly state needs and preferences to anyone, without prompting
Some understanding of needs and preferences, but struggles to communicate them
Little to no understanding of needs and preferences without being given choices or suggestions
Little to no opportunity to express needs or preferences
MPower Me workshops offer opportunities to interact with peers and learn about improving independence. Which of the following would engage your Student the most?
Prompting (e.g. scheduled activities like taking meds, getting ready to go somewhere, etc.)
Checklists (e.g. names of people in the room, types of pets, days of week, etc.)
Priming/ preparing (e.g. watch a video about arriving to an appointment before doing it)
Self-reporting activities, feelings, opinions (e.g. emoticons, selfie pictures, video instructions)
Mobile device preferences (e.g. screen brightness, volume, alarms, narrated voice pitch)
Please describe your priorities or expectations for your Student's participation in the MPower Me workshop.
Does your Student have any specific interests they like to talk about?
Are there any sensitive subjects that upset the Student that you would like us to avoid if possible?
Do you have any questions or comments for MPower Me at this time?
A copy of your responses will be emailed to the address you provided.
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