Life After Film Screening Registration Form
Name
*
First Name
Last Name
E-mail
*
example@example.com
Rutgers affiliation
*
Please Select
Student
Faculty
Staff
Not affiliated with Rutgers
Which best describes you?
*
Student
Professional/Provider
Self-advocate/Person with a disability
Family member/caregiver
Community member
Other
Organization or School
Role/Title
Do you require any disability-related accommodations to participate?
*
No
Yes
Please describe the disability-related accommodations you need to participate
How did you hear about this event?
Website
Email
Social media
My professor or academic department
Other
Media Consent
I give Rutgers permission to record my image and/or voice and grant Rutgers all rights to use these recordings or photographs in any medium for educational, promotional, advertising, or other purposes that support the mission of the university
Submit
Should be Empty: