Welcome To Arizona Achieve

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Disclaimer: The information collected in this form is solely for the purpose of gathering demographic data required by ADDPC (Arizona Developmental Disabilities Planning Council) and to track the progress of self-advocates as we move forward. We value your privacy and assure you that all information provided will be kept confidential and used strictly for the stated purposes. Your support in this process will enable us to better understand the needs and experiences of self-advocates, thereby enhancing the effectiveness and inclusivity of Arizona Achieve. Thank you for your cooperation to promote self-advocacy in Arizona.

Email *

Name (First And Last) *

What is your phone number? *

Age *

What is the name of your emergency contact? *

What is the emergency contact's phone number? *

I identify my race as: *

American Indian or Alaskan Native (AIAN)

Asian American

Black or African American

Hispanic/Latino

Native Hawaiian or other Pacific Islander

White or Caucasian

Race unknown

Prefer not to answer

Required

My current gender is: *

Female

Male

Transgender

Two-Spirit (if you are AIAN)

I use a different term

Don't know

Prefer not to answer

Other:

I am participating with Arizona Achieve as: *

Person with an intellectual and/or developmental disability (I/DD)

Person with another disability (not I/DD)

Family member/Caregiver

Professional (not identified as either Person with an I/DD and/or Family member)

Prefer not to answer

I live in this Arizona County: *

Apache

Cochise

Coconino

Graham

Gila

Greenlee

La Paz

Maricopa

Mohave

Navajo

Pima

Pinal

Yavapai

Yuma

Prefer not to answer

Live outside Arizona

What accommodations do you need? *

Sign language interpreter

Closed captioning/subtitles

Braille materials

Large print materials

Accessible seating

Assistive listening devices

Wheelchair accessibility

Audio description

Tactile or sensory accommodations

None

Required

Other accommodations? (please specify below)

Do you have a guardian? *

Yes

If you answered yes, what type of guardianship do you have?

Full guardianship

Limited guardianship

Power of attorney

Not sure

Clear selection

Are you with any self-advocacy groups? (please specify below) *

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