Arkansas Self-Advocates Present (ASAP) Network Workshop Sign-Up

Name*

First NameLast Name

Pronouns*

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is your mailing address different?*

YesNo

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Preferred Method of Communication*

EmailPhone Call

Age*

Gender*

How would you describe yourself? (Select all that apply):

Are you a person with a disability/disabilities?*

YesNo

If it's okay with you, can you tell us more about your disability? We want to make sure we reach out to a wide range of self-advocates in the future.

This program is exclusively for people with disabilities in Arkansas. If you are interested in learning more about advocating for people with disabilities, please look at our website here: www.disabilityrightsar.org

Do you require American Sign Language (ASL) interpreter services?*

YesNo

Do you require other language translation services?*

YesNo

Please specify:

Please check if any below formats are required when resources are given to you:

Large Print (Please provide a sample)BrailleOther

Will your Direct Support Professional or Direct Care Aide come to the sessions with you?

YesNo

Other Accessibility Accommodations

Describe any specific dietary needs (e.g. low salt, vegetarian, sugar free, etc.)

Do you have transportation to and from workshops, meetings and presentations?*

YesNo

How will you be attending the sessions for this workshop?*

In-PersonVirtual

Do you have a computer or laptop with a microphone and camera?*

YesNo

Do you have access to the internet?*

YesNo

Have you used Zoom before?*

YesNo

Do you have a LinkedIn profile?*

YesNo

Tell us about yourself.*

List any current or previous work experience with start/end dates and tell a little bit about what you did/do: Example: Target - Cashier, June 2022 – Still Working (Help customers by checking them out)

If you are in school, please describe the classes you are taking and where.

List any current or previous organizations you volunteer at with start/end dates and tell a little bit about what you did/do: Example: Little Rock Animal Shelter - Volunteer, January 2020 – April 2021 (Help clean cages, play with animals and feed them)

What are some of your personal interests? *

Please identify one or two topics that you feel your community is lacking in knowledge related to disability. *

Are you currently comfortable with public speaking?*

YesNo

Talk about any experience you have giving presentations/public speaking:

Why are you interested in joining the Arkansas Self-Advocates Present (ASAP) Network? *

Photo/Social Media Release

I hereby grant permission to Disability Rights Arkansas to use photographs and/or video of me taken during the duration of the ASAP Program in publications, news releases, digital media, and in other communications related to the mission of the Alliance and Disability Rights Arkansas.

Arkansas Self-Advocates Present (ASAP) Network Workshop Sign-Up

Personal Information

Demographic Information

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