Self-Advocate Interest Survey

 

Are you interested in self-advocacy?  Please help us by answering these questions.

 

Why is self-advocacy important to you?
What does self-advocacy mean to you?
Tell us something you have done that has helped you get something you wanted.
What things are important to you that you would want to work on changning? ...that effects you?
....that effects others as well as you?

 

Are you interested in working on self-advocacy:
A)  in your community Yes No

B)  on developing a state-wide association

Yes

No

 

What support would you need in order to participate?  (transportation, personal assistance, etc.)
Is there anything else you want us to know?

 

Please tell us about you!

 

Your Name:  

 

Your Address:

Street:

 

City:

   State:

  Zip:

  County:

 

Your Phone:  

Your e-mail:

 

If someone helped you complete this, please tell us about this person:

 

Name:

Relationship:
Agency: (If applicable)