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* 1. First Name

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* 2. Last Name

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* 3. Address

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* 4. Will you be bringing a direct support professional?

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* 5. Direct Support Professional's name?

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* 6. Are you a person with a I/DD

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* 7. Are you a family member of a person with I/DD?

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* 8. Do you use a mobility device?

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* 9. Are you bringing an ADA service animal?

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* 10. What accommodations do you need to fully participate?

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* 11. Will you need help identifying or contacting your legislators to set an appointment to meet with them?

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* 12. Do you have any dietary restrictions?

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* 13. Dietary needs

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* 14. Special diet needs or allergies. List all that apply. 

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* 15. Do you need milage reimbursement? Note this will be evaluated at the Council's discretion

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* 16. I, the undersigned, hereby grant permission to Michigan Developmental Disabilities Council, its representatives, employees, agents, and partners the irrevocable and unrestricted right to use, reproduce, and publish my photos, videos, and interviews for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium.  

I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be produced using them now or in the future, whether that use is known unknown to me. I also waive any right to compensation and release Michigan Developmental Disabilities Council from any and all liability which may arise from the use of such media.

By agreeing to this release, you are recognizing that you are at least 19 years old or the legal parent or guardian of the subject who is under 19 years old, have read and understood the previous statements, and are able to contract in your own name.

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