Registration Form

Registration Form

Powering Through Life by People with Disabilities --Independent Living Part 4
Powering Through Life by People with Disabilities -- Independent Living Part 4:
- Relationships and Intimacy
- Aging Experiences and Process
- End-of-life Planning
- Open Discussion
Date*

MonthDayYear
Date
Name*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
I will be attending In-Person or Virtually:

In-Person (Nov 16, 2023 at 4:00pm-6:00pm)Virtually (Nov 30, 2023 at 4:00pm-6:00pm)
I will be attending In-Person or Virtually:

In-Person (Jan 11, 2023 @ 4:00pm-6:00pm)Virtually (Jan 25, 2024 @ 4:00pm-6:00pm)
I will be attending In-Person or Virtually:

In-Person (Mar 12, 2024 4:00pm-6:00pm)Virtually (Mar 28, 2024 4:00pm-6:00pm )
I will be attending In-Person or Virtually:*

In-Person (May9, 2024 4:00pm-6:00pm)Virtually (May 23, 2024 4:00pm-6:00pm )
Will you need an accommodation?*

YesNo
Please explain your accommodation needs:*
Type N/A if you do not need an accommodation
Are you 18 years of age or older? (You must be 18 years of age or older.)*

YesNo
I am participating in this conference as:*

Person with an intellectual/developmental disabilityPerson with a disabilityFamily member/CaregiverProfessional (not identified as either a person with a disability)Prefer not to answerOther
I identify my race as:*

American Indian or AlaskanAsian AmericanBlack or African AmericanHispanic/LatinoNative Hawaiian or other Pacific IslanderWhite or CaucasianTwo or more racesRace unknownPrefer not to answer
I live in this Arizona County:*

ApacheCochiseCoconinoGrahamGilaGreenleeLa PazMaricopaMohaveNavajoPimaPinalYavapaiYumaPrefer no to answerLive outside Arizona
My current gender is:*

FemaleMaleTransgenderTwo-SpiritI use a different termDon't knowPrefer not to answer
Is there anything else you would like to tell us?
You will receive an email to complete a Zoom registration if you attend remotely. It must be completed to participate.
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