Self-Determination Training

Self-Determination Sign-in/Registration

Question Title

* 1. Are you able to attend at least one of our upcoming trainings on May 14th or May 15th?

Yes

Yes - But Only on Facebook Live

No

Question Title

* 2. Which site will you be attending

Stockton

Modesto

Facebook

None

Question Title

* 3. Contact Information (Minimum Required: Your Name, Consumer's Name, and Consumer's Birthdate and or UCI#)

Name

Consumer's Name (if you are a family member of a consumer)

Consumer's UCI # (this is not required but can be found on the IPP)

Address

City/Town

State/Province

ZIP/Postal Code

Consumer's Date of Birth

Email Address

Phone Number

Question Title

* 4. Are you already on the "Interested List"

Yes

No

Don't Know

Question Title

* 5. Would you like to be added to the interested list?

Yes

No

Not sure yet

Question Title

* 6. Do you need Spanish Language translation services?

Yes

No