Diverse Ability Incorporated Peer Services: School/Agency Request Form

Diverse Ability Incorporated Peer Services: School/Agency Request Form
Diverse Ability Incorporated offers peer-led programs for students who have disabilities. These programs uniquely address several of the Pre-ETS areas of service. Our trained young adult leaders, who also have disabilities, educate and motivate students through hands-on learning experiences that build on individual strengths, promote independence, and help them achieve their goals and dreams. Our peer-led programs include:
- Peer-Based, Person-Centered Planning (approximately 12 hours)
- Skills to Pay the Bills (approximately 12 hours)
To learn more about these services, please visit our Peer-Based Programs for Schools webpage.

Please complete this form to request programming for your students. If you have any questions or concerns, please email the DAI Admin Inbox.
Contact Information

Please provide the contact information for the individual filling out this form.
First Name*
Last Name*
Title/Role*
Email*
example@example.com
Phone Number*

Area CodePhone Number
I work for a:*

SchoolOrganization/Agency
School District
Organization/Agency
Program(s) and Availability
I am interested in the following program(s):*

Peer-Based, Person-Centered Planning (approximately 12 hours)Skills to Pay the Bills (approximately 12 hours)
What date would you like the programming to start?*

MonthDayYear
By what date must programming conclude?*

MonthDayYear
On which day(s) and at what time(s) would you like DAI to provide the programming?*
Please provide any available days and blocks of times. Diverse Ability Incorporated can offer up to four hours of programming at a time.
Are you interested in programming more than one day a week?

YesNo
Please share which days or combinations of days would work best for you.
Please share any additional information that may affect the scheduling.
Examples: Holidays, school breaks, scheduled field trips, state testing dates, etc.
Please share any additional information that may affect the scheduling.
Examples: Holidays, closures, etc.
Class Information
Program Information
Teacher Contact Information

Please provide the contact information for the classroom teacher if it differs from the information listed above.
Teacher First Name
Teacher Last Name
Teacher Email
Teacher Phone Number

Area CodePhone Number
Location Information
School/Program Name*
Location Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Room Number (where programs will be facilitated)
Student Information

We are committed to ensuring our programs are accessible to all. Please answer the following questions so we can best serve your students.
Number of Students*
Please provide a general overview of your students' disabilities*
Please share any accommodations, techniques, or supports that would aid your students' learning. *
Additional information or comments (i.e., other factors that could affect student completion of programs)
Participant Information

We are committed to ensuring our programs are accessible to all. Please answer the following questions so we can best serve your participants.
Number of Participants*
Please provide a general overview of your participants' disabilities*
Please share any accommodations, techniques, or supports that would aid your participants' learning. *
Additional information or comments (i.e., other factors that could affect participant completion of programs)
If you have difficulty completing this online form, please email us or call 602-425-5135.
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Diverse Ability Incorporated Peer Services: School/Agency Request Form

Contact Information

Program(s) and Availability

Class Information

Program Information