Please describe your disability (This will assist in assuring that we include delegates – (students) with diverse disabilities) Primary Disability (medical diagnosis): Onset of Disability (age): Please check all that apply: Deaf / Hard of Hearing: Autism I use sign language Asperger’s syndrome I use assistive listening devices Traumatic Brain Injury I use real time captioning Down Syndrome I use lip reading Intellectual Disability I need interpreter services Mental Health Disability (e.g. anxiety, I use note takers depression, bipolar/mood disorder, Blind / Visually Impaired: obsessive compulsive disorder, other) I read with Braille Neuro/Muscular Disability I read with large print Learning Disability (e.g. dyslexia, I need assistance with mobility dyscalculia, ADD/ADHD, other…) I prefer electronic format Reading Math Written Mobility Disability (e.g. spinal cord injury, Multiple Disabilities muscular dystrophy, other): Chronic Illness (e.g. cancer, cystic fibrosis, I use a wheelchair / scooter diabetes, heart disease, other) I cannot walk upstairs Chemical / Environmental Sensitivity I use a walker, cane, or crutches Other (describe) I cannot walk long distances Immune Disability: Crohn’s Disease Rheumatoid Arthritis Sickle Cell Anemia Other Please list all accommodations needed to participate in the Forum (interpreter, personal care attendant, special diet, etc.) Short answer and Essay: Complete the following questions. If you are using a scribe to complete this portion of the application, please make sure responses are written reflecting your voice. If you have questions or need assistance with completing this application please contact Wendy at 800-877-8249 or wendy.molitor@oa.mo.gov. What organizations or activities are you involved in with your school and/or community? This may include any offices you held, club memberships, after school activities, work experience, church activities, community volunteer, etc.
Please describe your disability – (This will assist in assuring that we include delegates (students) with diverse disabilities) Primary Disability (medical diagnosis): Onset of Disability (age): Please check all that apply: Deaf / Hard of Hearing: I use sign language I use assistive listening devices I use real time captioning I use lip reading I need interpreter services I use note takers Blind / Visually Impaired: I read with Braille I read with large print I need assistance with mobility I prefer electronic format Mobility Disability (e.g. spinal cord injury, muscular dystrophy, other): I use a wheelchair / scooter I cannot walk upstairs I use a walker, cane, or crutches I cannot walk long distances Immune Disability: Crohn’s Disease Rheumatoid Arthritis Sickle Cell Anemia Other Autism Asperger’s syndrome Traumatic Brain Injury Down Syndrome Intellectual Disability Mental Health Disability (e.g. anxiety, depression, bipolar/mood disorder, obsessive compulsive disorder, other) Neuro/Muscular Disability Learning Disability (e.g. dyslexia, dyscalculia, ADD/ADHD, other…) Reading Math Written Multiple Disabilities Chronic Illness (e.g. cancer, cystic fibrosis, diabetes, heart disease, other) Chemical / Environmental Sensitivity Other (describe) Please list all accommodations needed to participate in the Forum (interpreter, personal care attendant, special diet, etc.) Short answer and Essay: Complete the following questions. If you are using a scribe to complete this portion of the application, please make sure responses are written reflecting your voice. If you have questions or need assistance with completing this application please contact Wendy at 800-877-8249 or wendy.molitor@oa.mo.gov. What organizations or activities are you involved in with your school and/or community? This may include any offices you held, club memberships, after school activities, work experience, church activities, community volunteer, etc.
2018-Forum-Application-for-Delegates.docx