Disability.mo.gov
ONLY COMPLETE APPLICATIONS WILL BE CONSIDERED (Application and References)Which Regional Leadership Forum would you like to attend? (Choose ONE) FORMCHECKBOX Jefferson City on March 13th FORMCHECKBOX Cape Girardeau on March 20th FORMCHECKBOX Kansas City on April 10th FORMCHECKBOX Springfield on April 17th Name: (First) FORMTEXT ?????(M.I.) FORMTEXT ?????(Last) FORMTEXT ?????Gender: FORMTEXT ????? Birth Date FORMTEXT ????? Race (Optional) FORMTEXT ????? T-Shirt Size FORMTEXT ????? Email Address FORMTEXT ?????Mailing Address FORMTEXT ?????City FORMTEXT ????? Zip FORMTEXT ?????County FORMTEXT ?????Phone FORMTEXT ?????Current Grade FORMTEXT ?????Expected Graduation Date FORMTEXT ?????High School FORMTEXT ????? School Phone FORMTEXT ?????Parent / Guardian FORMTEXT ????? Phone FORMTEXT ?????Parent Email FORMTEXT ?????Please check the ones that apply:How did you learn about the Forum? FORMCHECKBOX School FORMCHECKBOX Friend FORMCHECKBOX Internet/E-mail/Social Media FORMCHECKBOX Transition Event FORMCHECKBOX Other FORMTEXT ?????I am a Vocational Rehabilitation (VR) or Rehabilitation Services for the Blind (RSB) Client FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t Know I am a DMH Regional Office client. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t KnowHave you participated at your local Center for Independent Living (CIL)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t KnowPlease describe your disability – (This will assist in assuring that we include students with diverse disabilities)Primary Disability (medical diagnosis): FORMTEXT ????? Onset of Disability (age): FORMTEXT ?????Please check all that apply: Deaf / Hard of Hearing: FORMCHECKBOX I use sign language FORMCHECKBOX I use assistive listening devices FORMCHECKBOX I use real time captioning FORMCHECKBOX I use lip reading FORMCHECKBOX I need interpreter services FORMCHECKBOX I use note takersBlind / Visually Impaired: FORMCHECKBOX I read with Braille FORMCHECKBOX I read with large print FORMCHECKBOX I need assistance with mobility FORMCHECKBOX I prefer electronic formatMobility Disability (e.g. spinal cord injury, muscular dystrophy, other): FORMCHECKBOX I use a wheelchair / scooter FORMCHECKBOX I cannot walk upstairs FORMCHECKBOX I use a walker, cane, or crutches FORMCHECKBOX I cannot walk long distancesImmune Disability: FORMCHECKBOX Crohn’s Disease FORMCHECKBOX Rheumatoid Arthritis FORMCHECKBOX Sickle Cell Anemia FORMCHECKBOX Other FORMTEXT ????? FORMCHECKBOX Autism FORMCHECKBOX Asperger’s syndrome FORMCHECKBOX Traumatic Brain Injury FORMCHECKBOX Down Syndrome FORMCHECKBOX Intellectual Disability FORMCHECKBOX Mental Health Disability (e.g. anxiety, depression, bipolar/mood disorder, obsessive compulsive disorder, other) FORMCHECKBOX Neuro/Muscular Disability FORMCHECKBOX Learning Disability (e.g. dyslexia, dyscalculia, ADD/ADHD, other…) FORMCHECKBOX Reading FORMCHECKBOX Math FORMCHECKBOX Written FORMCHECKBOX Multiple Disabilities FORMCHECKBOX Chronic Illness (e.g. cancer, cystic fibrosis, diabetes, heart disease, other) FORMCHECKBOX Chemical / Environmental Sensitivity FORMCHECKBOX Other (describe) FORMTEXT ?????Please list all accommodations needed to participate (interpreter, special diet, etc.) FORMTEXT ?????Short answer: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 Rachel at 573-526-4564 or rachel.rackers@oa.. 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. FORMTEXT ?????List 3 goals that you have for your future. FORMTEXT ?????List 3 leadership strengths that you possess. FORMTEXT ?????ReferencesPlease list three references that we may contact by phone. One reference must be a high school principal, counselor, or a teacher. The other references may be any adult who knows you well, other than a parent or relative, for example, scout leader, employer, coach, community leader, etc. At least one reference must be from outside the school. 1. Name (School) FORMTEXT ?????Phone FORMTEXT ?????2. Name FORMTEXT ?????Phone FORMTEXT ????? 3. Name FORMTEXT ?????Phone FORMTEXT ?????If unable to submit online you may email, fax, or mail your documents to:Governor’s Council on DisabilityMissouri Youth Leadership ForumPO Box 1668Jefferson City, MO 65102rachel.rackers@oa.: 800-877-8249Fax: 573-526-4109 ................
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