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5/5/11 Webinar Registration Form
1. 5/5/11 Webinar: 250% Medi-Cal Working Disabled Program
Please fill out the following pieces of information to register for the webinar.
1
. Name:
Name:
*
2
. Email address:
Email address:
3
. Mailing address:
Mailing address:
4
. Phone number (in the event you are experiencing technical difficulties during the webinar):
Phone number (in the event you are experiencing technical difficulties during the webinar):
5
. Type of computer you will be using for the webinar:
Type of computer you will be using for the webinar:
PC (Windows)
Mac/Apple
6
. Accommodations: The webinar technology we are currently using is fully accessible to screen readers.
Do you require closed captioning?
Accommodations: The webinar technology we are currently using is fully accessible to screen readers. Do you require closed captioning?
Yes
No
7
. Agency or Organization you are representing:
Agency or Organization you are representing:
None (consumer/beneficiary)
One-Stop Career Center/Disability Program Navigator
One-Stop Career Center/Other
Employment Development Department/State
Department of Rehabilitation/Regional Office
Department of Rehabilitation/State
WIPA/Community Work Incentive Coordinator (CWIC)
WIPA/Other
Social Security Administration/Area Work Incentive Coordinator (AWIC)
Social Security Administration/Other
Regional Center
Department of Health Care Services/State
County Welfare Office/local Medi-Cal Office
Independent Living Center
Other benefits planner/counselor
County Mental Health Provider
Disability Rights California
Other (please specify)
8
. Do you provide direct services to people with disabilities?
Do you provide direct services to people with disabilities?
Yes
No
9
. Would you like to receive invitations for future training webinars?
Would you like to receive invitations for future training webinars?
Yes
No
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