Join usĀ on Monday, February 17 - Friday, February 21 from 10:00am - 3:00pm at Boston Center for Independent Living located at 60 Temple Place Floor 5, Boston, MA 02111.

Please fill in your information below. If you have any questions, comments, or concerns about this form, please contact Program Coordinator, Jeremy Gooden, at jgooden@bostoncil.org. Thank you!

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. When is your birthday?

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* 4. What is your phone number?

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* 5. What is your email?

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* 6. What is your parent/guardian's email?

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* 7. What is your parent/guardian's phone number?

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* 8. We will be teaching participants how to travel to and from Boston Center for Independent Living. Would you be interested in learning how to ride the Boston subway trains? If so, please tell us what subway line is closest to your home address.

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* 9. Accommodation request?  Please tell us what you need during the workshop.

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