SABE Membership Form Survey

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1. Please complete this Form and provide all information requested.

(Note: To Apply you must be a Legal US citizen.)

Please complete this Form and provide all information requested. (Note: To Apply you must be a Legal US citizen.) First name and middle initial
Last name
Street Address Line 1:
Streed Address Line 2:
City/Town:
State:
ZIP/Postal Code:

Email Address:
Phone Number:

2. Type of membership (select one)

Type of membership (select one) Self-Advocate (Voting): $15

Self-Advocacy Organization: $25

Individual: $20

Agency: $100

Corporation: $500

Other (Donation/In Memory of or In Honor of...)

3. Total due

Total due

4. Method of payment

Method of payment

Please make checks payable to Self Advocates Becoming Empowered

Send the confirmation page and checks/money orders to: Self Advocates Becoming Empowered Attn: Rachel Hiles P.O. Box 30142 Kansas City, MO 64112

SELF ADVOCATES: Please fill out the questions below to help us know and serve you better!

5. Gender

Gender Male

Female

6. Work

Work Community

Sheltered

None

Other (please specify)

7. School

School High School

Post-secondary

None

Other (please specify)

8. Age

Age Under 18

18-22

23-35

36-50

51-62

Over 63

9. Do you belong to a local/state self-advocacy group?

Do you belong to a local/state self-advocacy group? Yes

No

If so, which one?

10. Has being a part of self-advocacy helped you live the life you want to live?

Has being a part of self-advocacy helped you live the life you want to live? Yes

No

11. In the personal lives of self-advocates you know, what do you think are the biggest concerns that you and others have? Select your top three choices by ranking 1 to 3.

	1	2	3
Labels	*In the personal lives of self-advocates you know, what do you think are the biggest concerns that you and others have? Select your top three choices by ranking 1 to 3. Labels 1	Labels 2	Labels 3
Transportation	Transportation 1	Transportation 2	Transportation 3
Closing Institutions	Closing Institutions 1	Closing Institutions 2	Closing Institutions 3
Community Living	Community Living 1	Community Living 2	Community Living 3
Sheltered Workshops	Sheltered Workshops 1	Sheltered Workshops 2	Sheltered Workshops 3
Inclusive Education	Inclusive Education 1	Inclusive Education 2	Inclusive Education 3
Money/Finances	Money/Finances 1	Money/Finances 2	Money/Finances 3
Community Employment	Community Employment 1	Community Employment 2	Community Employment 3
Social/Recreation	Social/Recreation 1	Social/Recreation 2	Social/Recreation 3
Relationships	Relationships 1	Relationships 2	Relationships 3
Housing	Housing 1	Housing 2	Housing 3
Guardianship	Guardianship 1	Guardianship 2	Guardianship 3
Other	Other 1	Other 2	Other 3

12. Where do you live?

Where do you live? Own my own home

On my own/roommate

With Family

Group Home

ICF/MR

Nursing Home

Institution

13. Are you (Check all that apply):

Are you (Check all that apply): Single

Married

Divorced

With children

14. Race (Optional)

Race (Optional) African American

Asian

Native American

Caucasian

Pacific Islander

Hispanic

Mixed

Other (please specify)

SABE Membership Form

Default Section

*1. Please complete this Form and provide all information requested.(Note: To Apply you must be a Legal US citizen.)

2. Type of membership (select one)

3. Total due

4. Method of payment

5. Gender

6. Work

7. School

8. Age

9. Do you belong to a local/state self-advocacy group?

10. Has being a part of self-advocacy helped you live the life you want to live?

11. In the personal lives of self-advocates you know, what do you think are the biggest concerns that you and others have? Select your top three choices by ranking 1 to 3.

12. Where do you live?

13. Are you (Check all that apply):

14. Race (Optional)

*
1. Please complete this Form and provide all information requested.

(Note: To Apply you must be a Legal US citizen.)