The Arc Ambassador Latino Workshops - APPLICATION If you have any questions about this application contact Patricia Gonzalez at 206-829-7027 or pgonzalez@arcofkingcounty.org Question Title * 1. Today's Date: Question Title * 2. Name: Question Title * 3. Address: Question Title * 4. Phone Number(s): Question Title * 5. Email Address: Question Title * 6. Year of Birth: Question Title * 7. What is your relationship to a person with a developmental disability (check all that apply)? I have a disability Parent Sibling Grandparent Other Family Member Professional Other (please explain): Question Title * 8. Age(s) of your loved one with a developmental disability: Question Title * 9. What kind of disability does your loved one have? (Check all that apply) ADD/ADHD Alzheimer's Disease Autism (including Asperger's) Cerebral Palsy Down Syndrome Dyslexia Epilespy Fetal Alcohol Syndrome Fragile X Syndrome Learning Disability Mental Health (such as depression, bipolar disorder, schizophrenia, etc.) Physical Disability Speech Impairment Traumatic Brain Injury BEFORE age 18 Traumatic Brain Injury AFTER age 18 Visual Impairment Other (please explain) Question Title * 10. Would you like to attend the workshops on SPECIAL EDUCATION? Dates: August 9, September 6, and September 27 - We require you to attend all three days Application due by July 26, 2014 Yes No Question Title * 11. Would you like to attend the workshops on PUBLIC BENEFITS? Dates: October 25, November 22, December 13 - We require you to attend all three days Application due by October 11, 2014 Yes No Question Title * 12. Would you like to attend the workshops on DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA) SERVICES Dates: January 10, February 7, March 7, 2015 - We require you to attend all three daysApplication due by December 22, 2014 Yes No Program Application Fees:* $30 for ONE 3-part workshop series (total of 3 workshops)* $50 for TWO 3-part workshop series (total of 6 workshops)* $60 for ALL THREE 3-part workshop series (total of 9 workshops)Please bring cash or check to first workshop --- Scholarships available********ALL APPLICANTS ARE ENCOURAGED TO APPLY FOR A SCHOLARSHIP!*********(Scholarships will cover all application fees) SCHOLARSHIPS ARE AVAILABLE! If you would like to be considered for a scholarship, compete the following questions. The Arc of King County will review your application and notify you of our decision. Question Title * 13. Tell us about yourself. (Feel free to type as much as you want.) Question Title * 14. Why do you want to participate in this program? What do you hope to learn and how will you use the information?(Feel free to type as much as you want.) Question Title * 15. Why should you receive this scholarship?(Feel free to type as much as you want.) If you have any questions about this application contact Patricia Gonzalez at 206-829-7027 or pgonzalez@arcofkingcounty.org Done