Disability Community Action Lab Interest

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Thank you for your interest! In order to get to know you a bit better and to get a sense of what you are interested in, please answer the following questions. This will also add you to our DCAL monthly newsletter.

If you need support or assistance in completing or submitting this form, please contact us at wpurves@aacil.org or call 734.971.0277x56

Email *

First and Last Name *

What is your phone number?

What county do you live in?

Washtenaw

Livingston

Monroe

Other:

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What is your ZIP code?

As a disability community advocate, what areas are you most interested in? (No experience is needed! Check all that apply)

Accessible Affordable Housing

Transportation

Medical Care

Health Insurance (including Medicare and Medicaid)

Social Security/Supplemental Income

Public Health

Accessible Public Spaces

Accessible Businesses/Workplaces

Voting

Other:

DCAL will ask you to access materials (e.g. reading, video, podcasts with transcriptions) and attend online virtual meetings. Therefore, a stable internet connection is helpful for participation. Is this possible for you at this time?

Yes, I can comfortably and reliably access the internet

I have reliable internet but I will need assistance with using it for this program

I feel comfortable in using the internet but I do not have consistent/reliable access

No, I can neither comfortably nor reliably access the internet

Other:

Clear selection

(Optional) If you have any access issues related to the internet, you may explain here:

What devices would you plan on using to navigate this online program?

Desktop or laptop computer

Smartphone

Tablet

Other:

Any other ways we can make this learning experience accessible to you?

A copy of your responses will be emailed to the address you provided.

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