1. Become a self-advocate with Yes! in Kentucky by completing this form!

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* 1. Please provide the following information:

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* 2. Please provide your telephone number (for the YES! in Kentucky Phone Tree):

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* 3. Please provide your email address (for YES! in Kentucky email blasts):

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* 4. Are you?

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* 5. What issues affecting Kentuckians with disabilities do you care about? Please rate the following items.

  Not important to me Somewhat important to me Important to me Very important to me
Accessibility to public accommodations
Adequate supports to live in the community independently
Affordable and Accessible Housing
Assistive Technology
Disability Benefits
Disability Rights
Employment
Healthcare
Health Insurance
Medicaid Insurance
Recreational opportunities
Transition
Transportation

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* 6. Do you have other issues important to you that are not mentioned above? Please tell us.

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* 7. Yes! in Kentucky! will be developing a Youth Leadership Council to assist in setting advocacy priorities and to conduct an annual Transition Summit. Would you be interested in being part of this Council?

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