Indiana Council on Independent Living Member Application

Exit this survey

 

1. First and Last Name

First and Last Name

2. Email Address

Email Address

3. Telephone Number

Telephone Number

4. Are you a person with a disability? If so, please indicate your disability below:

Are you a person with a disability? If so, please indicate your disability below:   Mental Health Mobility Deaf/Hard of Hearing Blind/Visually Impaired Cognitive Neurological

5. Are you a parent or sibling of a person with a disability?

Are you a parent or sibling of a person with a disability?   yes no

6. Please tell us how you learned about ICOIL and if you have had involvement with ICOIL in the past.

Please tell us how you learned about ICOIL and if you have had involvement with ICOIL in the past.

7. Are you able to perform the duties of a member and make a commitment to attend a minimum of one regularly scheduled two hour council meeting on a monthly basis? If you were to be appointed to ICOIL how soon would you be available to begin serving on the council?

Are you able to perform the duties of a member and make a commitment to attend a minimum of one regularly scheduled two hour council meeting on a monthly basis? If you were to be appointed to ICOIL how soon would you be available to begin serving on the council?

8. What do you believe are the most important issues facing people with disabilities today?

What do you believe are the most important issues facing people with disabilities today?

9. Please tell us a little about yourself and why you would like to be appointed to ICOIL?

Please tell us a little about yourself and why you would like to be appointed to ICOIL?

10. I hereby give permission for ICOIL to contact any volunteer or advocacy organizations, and references.

I hereby give permission for ICOIL to contact any volunteer or advocacy organizations, and references.   Agree Disagree