Upon completion of the application, you will be connected to the My Life, My Rights 8-module video course.

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* 1. Name:

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* 2. Enter contact information below:

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* 3. Preferred Mode of Contact:

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* 4. Agency of Services:

Please complete the following demographic questions which are required for reporting purposes:

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* 5. Date of Birth:

Date

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* 6. Gender:

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* 7. Race/Ethnicity:  (Please choose only one.)

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* 8. Do you associate with a disability:

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* 9. Please enter your social security number (with dashes) and/or your DMH ID number below.

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