Peer-to-Peer, Coast-to-Coast Registration Form

Equip and Dayle McIntosh Center Presents: Peer-to-Peer, Coast-to-Coast

Welcome to the Peer-to-Peer, Coast-to-Coast Hangout registration form!
Event Location
Virtual over Zoom

Date & Time

The first Saturday of every month

11 am to 12 pm PT

2 pm to 3 pm ET

Event Details

Registered participants will be able to join us virtually on Zoom. Join us to connect with other youth with disabilities, ages 13 to 28, 3000 miles apart!

Peer-to-Peer, Coast-to-Coast Registration Forms

Following are the Peer-to-Peer, Coast-to-Coast Registration, Photo Release, and Goals and Rights Forms. After submitting the forms, you will see a confirmation page with reminders. Also a copy of your answers will be emailed to you (One important note. We are not able to email school emails. Please only provide personal emails you have access to!)
Name*

First NameMiddle NameLast Name
Preferred Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
What is your birthday?*

MonthDayYear
HispanicWhiteAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderNative American or Alaskan NativeOther
Language spoken at home?*
If other, what language do you speak at home?
Gender*
Gender not listed
Preferred Pronouns
What state do you live in?*
What County do you live in?*
If other, what is that county?
What is your primary disability?*
If you selected Other, what is that disability?
Do you have any other disabilities?
Do you need any accommodations for this event?
Middle SchoolHigh SchoolCollege/UniversityNot in School
Select Your Middle School or High School
If you selected other, what is that High School?
Name of Your College/University
If other, please type the name of your college/university.
YesNo
YesNoUnsure, follow up with me

Peer-to-Peer, Coast-to-Coast Photograph & Video Release Form
Dear Participants/Parents/Guardian: During activities, we may take photographs of activities involving participants to share positive vibes and updates. Incidentally, some photographs may capture any of our participant's participation, directly or indirectly. By signing this form, you consent and agree that the Equip Leadership Group, Able South Carolina, Dayle McIntosh Center, their employees, or agents have the right to take photographs and digital recordings of me/my child and to be used in any and all media resources.

By agreeing to this form, you release the Equip Leadership Group, Able South Carolina, Dayle McIntosh Center, its agents, and employees all rights to exhibit this work in print and electronic form publicly.
Name of Participant*
Participant's Birthday*

MonthDayYear
Name of Guardian (if under 18)
I hereby allow the reproduction and publication of my photograph(s)I do not allow the reproduction and publication of my photograph(s)
I hereby allow the reproduction and publication of my child's photograph(s)I do not allow the reproduction and publication of my child's photograph(s)
Type Your First And Last Name As Your Signature To Agree With Your Answers*

First NameLast Name

Goals and Rights
Consumer Anti-Discrimination Statement:

Able South Carolina is committed to providing an inclusive and welcoming environment for all individuals and ensures equal opportunities and services to the consumers we serve. Able South Carolina does not and shall not discriminate on the basis of age, disability and/or type of disability, race, color, religion (creed), gender, gender expression, national origin (ancestry), marital status, sexual orientation, or military status, in any of our services, activities or operations.
Yes
Right to Seek Mediation:

If, as a client/consumer of Able South Carolina, you are unsatisfied with a decision concerning your eligibility, other decisions made regarding your case, or the services we provide, you have the right to the following:
1. Contact our Director of Community Outreach & Consumer Rights to share your concerns. She can be reached at 1.800.681.6805
2. If you are not satisfied with the resolution, contact our President & CEO. She can be reached at 1.800.681.6805.
3. If you are still not happy, you may contact South Carolina’s Client Assistance Program (CAP) at 1-866-275-7273. A CAP brochure is provided to every new consumer
Yes
Right to Confidentiality:

All information pertaining to you and your family will be kept confidential unless you provide a written request that we release the information or unless we are required to do so by court order. You also have the right to review your record at any time.

Able South Carolina receives federal funding to provide services. Occasionally, the federal agencies that oversee our funding will review our records to ensure we are using our funds properly. The agency staff may select your file for review. These staff members are bound by the same confidentiality rules as Able SC staff and cannot share your information with anyone.
Yes
My Goal While Working with Equip:

My goal is to actively participate in the Equip program, becoming a key part of this supportive community. I want to connect with my peers with disabilities who share similar experiences, giving and receiving support. I aim to gain independence and learn how to tackle obstacles in my path with the skills I'll develop. Above all, I am determined to break down barriers I face and become more self-reliant, using my newfound abilities to contribute back to my community.
Bet (Yes)
By clicking 'Submit', you will have completed the form and cannot make any edits. If you have any questions, please email equip@able-sc.org.
Should be Empty:

Equip and Dayle McIntosh Center Presents: Peer-to-Peer, Coast-to-Coast

Peer-to-Peer, Coast-to-Coast Registration Forms

Peer-to-Peer, Coast-to-Coast Photograph & Video Release Form

Goals and Rights