Application

ADULT SIBLING LEADERSHIP NETWORK APPLICATION

Please print legibly:

 NAME:

 STREET ADDRESS:

 CITY:                                               COUNTY:                                    ZIP:

 VOTING DISTRICT:  ________ House District   _________Senate District   (To find your voting district go to: https://webprod.cio.sc.gov/SCSECVoterWeb/voterInformationSearch.do )

 HOME  NO:  (      )                         WORK NO:  (     )                       CELL NO:  (     )

 E-MAIL ADDRESS:                                                   COMPUTER ACCESS:  _____ Yes  ____  No

 ARE YOU:       _____ MALE _____  FEMALE    RACE/ETHNIC BACKGROUND:

YOUR AGE:   _____   21-44       _____  45-64     _____  65+                  

YOUR MARITAL STATUS:  _____ Single   _____ Married 
If you have children, ages of your children __________________________________________

DO YOU HAVE A RELATIVE/FRIEND WHO HAS A DISABILITY? (Please answer for each relative/friend if you have more than one with a disability.  (See definitions in brochure.)

Relationship

Brother

Sister

Relative

Friend

Disability (intellectual disability, autism, related disability, brain injury, spinal cord injury)

 

 

 

 

Age of Individual with a Disability

 

 

 

 

Individual with a Disability lives in SC? 
         Yes (Y) or No (N)

 

 

 

 

Lives at home with family?     Y or N

 

 

 

 

Lives in a supervised living apartment? 
         Y or N

 

 

 

 

Lives in a group home?      Y or N

 

 

 

 

Lives in a regional center?      Y or N

 

 

 

 

Lives in a nursing home?      Y or N

 

 

 

 

AREAS OF INTEREST:

_____  Receive training and information to help me in my role as a relative/friend.

_____  Have opportunities to network with others through training seminars, conferences, & meetings.  

_____  Become a more effective advocate on behalf of my relative/friend with a disability. 

_____  Receive information through: _____  newsletters        _____  network meetings
                                                            _____  webinars            _____  conferences

                                                            _____  seminars            _____  other (specify) ____________

                                                            _____  fact sheets

_____  Become a member of an adult sibling support network.
_____  Become a facilitator of an adult sibling support network.          

I give permission for my name and email address to be included in an Adult Sibling Directory.   ___ Yes ___ No

I give permission for my name and email address to be added to the list serve.   ___ Yes ___ No

 I give permission for my name and email address to be shared with Legislative Advocacy organizations specific to my relative's/friend's disability.   ___ Yes ___ No

 I prefer to receive information:  ____  Electronically  ____US Mail

Signed: ________________________________________________ Date:    ____________________


(A pdf version of the application can be viewed below.)

Ċ
burnettiandr@aol.com,
Mar 28, 2012, 12:06 PM
Comments