UnlockGA Coalition Recruitment Form

Thank you for Joining UnlockGA!

UnlockGA aims to improve Home and Community-Based Services (HCBS) in Georgia by bringing together people and organizations dedicated to expanding access and quality within the HCBS system.

Through community organizing and advocacy, UnlockGA will work to protect and improve HCBS in Georgia.

The National Leadership Consortium and Georgia Council on Developmental Disabilities (GCDD) are leading a project to improve Home and Community-Based Services (HCBS) in Georgia and develop and continue the momentum of the Stronger Together Coalition.

By joining the Stronger Together Coalition, you can be part of a diverse, statewide effort to make real, lasting change for individuals who rely on HCBS every day.

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* Contact Information

Name

Last Name

Verify Email

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* Which of the following describe you?
Choose all that apply

A person with a developmental disability

A family member of a person with a developmental disability

A field professional who works for an organization that provides HCBS supports

A field professional or advocate who works for an organization that influences HCBS supports

A field professional or advocate who works for another type of organization (not listed above)

None of these

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* What is your gender?
Identifying information about you will not be shared

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* Are you of Spanish, Hispanic, or Latino origin?

Yes

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* Choose one or more races that you consider yourself to be part of

White or Caucasian

Black or African American

American Indian/Native American or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Prefer not to say

Other (please specify)

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* How old are you?

Under 18 years old

18-24 years old

25-34 years old

35-44 years old

45-54 years old

55-64 years old

65+ years old

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* In what county do you live?

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* What is your address?
We may send you flyers or SWAG (stuff everybody gets) for being an UnlockGA member

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* What are your top advocacy priorities related to HCBS supports in Georgia?

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* Who else do you recommend we recruit to the GA HCBS Coalition?

Person 1 Name & Last Name

Person 1 Email

Person 2 Name & Last Name

Person 2 Email

Person 3 Name & Last Name

Person 3 Email

UnlockGA Coalition Recruitment Form

Question Title

* Contact Information

Question Title

* Which of the following describe you?Choose all that apply

Question Title

* What is your gender?Identifying information about you will not be shared

Question Title

* Are you of Spanish, Hispanic, or Latino origin?

Question Title

* Choose one or more races that you consider yourself to be part of

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* How old are you?

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* In what county do you live?

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* What is your address?We may send you flyers or SWAG (stuff everybody gets) for being an UnlockGA member

Question Title

* What are your top advocacy priorities related to HCBS supports in Georgia?

Question Title

* Who else do you recommend we recruit to the GA HCBS Coalition?

* Which of the following describe you?
Choose all that apply

* What is your gender?
Identifying information about you will not be shared

* What is your address?
We may send you flyers or SWAG (stuff everybody gets) for being an UnlockGA member