Name

Email

Best Phone Number to reach you at

What city or town do you live in?

How would you like to be contacted? How would you like to be contacted? Email Phone No preference, I can be contacted by either email or phone

Are you a member of a local self-advocacy group? Are you a member of a local self-advocacy group? Yes No Not sure

If so, which local group?

If not, would you like information about local self-advocacy groups in your area? If not, would you like information about local self-advocacy groups in your area? Yes No Not sure

If you would like to be a member of an OSAC committee, choose one or more you are interested in: If you would like to be a member of an OSAC committee, choose one or more you are interested in: Legislative Employment Health Care Housing None

I am a (choose one) I am a (choose one) Self-advocate or person with IDD Supporter (family member of a self-advocate or person with IDD; professional or other)

I identify as (choose one): I identify as (choose one): Male Female Non-binary / third gender Prefer not to say

If you prefer to self-identify, type your answer here:

I identify as (choose one) I identify as (choose one) White or Caucasian Black or African American Native American or Alaska Native Asian Native Hawaiian or Other Pacific Islander Hispanic or Latino/a Two or more races Prefer Not to Say

I identify as a member of the Lesbian, Gay, Bisexual and/or Transgender (LGBT) community (choose one) I identify as a member of the Lesbian, Gay, Bisexual and/or Transgender (LGBT) community (choose one) Yes No No, but I identify as an ally Prefer not to say

Where I live (Choose one) Where I live (Choose one) Group home Foster home In my own home or apartment In my family's home Other (please describe below)

If "Other" please describe

Have you experienced homelessness? (Choose one): Have you experienced homelessness? (Choose one): Yes No

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