All applications are due March 1, 2012. You may copy and paste the application text below into an email or Word document and send it to Josue Rodriguez at adaptyouthsummit@yahoo.com.
NATIONAL ADAPT YOUTH SUMMIT TRAINING
STAY TUNED FOR UP COMMING DATES!!!
CHICAGO, IL
NAME: (LAST):
(FIRST):
CURRENT ADDRESS:
STREET:
APARTMENT OR UNIT #:
CITY:
STATE:
ZIPCODE:
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
STREET:
APARTMENT OR UNIT #:
CITY:
STATE:
ZIP CODE:
DATE OF BIRTH:
PRIMARY PHONE/ TTY # :
CELL PHONE/ TTY#:
FAX:
E-MAIL:
T-SHIRT SIZE:
PLEASE INDICATE WHICH IS THE BEST WAY TO CONTACT YOU:
HOME PHONE/ TTY
CELL PHONE ABILITY TO RECEIVE TEXTS
WHAT IS YOUR CELL PHONE #( )
FAX
E-MAIL
REGULAR MAIL/ SNAIL MAIL
DISABILITY ACCOMMODATIONS
BRAILLE MATERIALS
LARGE PRINT MATERIALS (FONT SIZE:_____)
PRINTED MATERIALS ON CD
SIGHTED GUIDE/ SCRIBE
ASL INTERPRETATION
WHEELCHAIR ACCESS
WILL YOU NEED PERSONAL CARE ATTENDANT
SERVICES?
WILL YOU BRING A PERSONAL CARE ATTENDANT WITH YOU?
IF YES, WHAT IS THE NAME OF THE PERSONAL CARE ATTENDANT:
GENDER OF ATTENDANT: MALE FEMALE OTHER: (PLEASE EXPLAIN)
OPTIONAL QUESTIONS
GENDER: ___MALE ___FEMALE __OTHER (Please describe if you want):
RACE OR ETHNICITY: CHECK ALL THAT APPLY
WHITE/ CAUCASIAN/EUROPEAN
BLACK/AFRICAN-AMERICAN/AFRICAN
HISPANIC/LATINO(A)
ASIAN/ SOUTH ASIAN/PACIFIC ISLANDER
INDIAN/NATIVE AMERICAN/FIRST NATION
BI-RACIAL/ MULTI-RACIAL
BRIEFLY ANSWER THESE QUESTIONS. FEEL FREE TO TYPE OR WRITE YOUR ANSWERS ON ANOTHER PIECE OF PAPER IF YOU NEED MORE SPACE!
1.WHAT IS YOUR DISABILITY? HOW DOES IT AFFECT YOU?
2. ARE YOU CURRENTLY INVOLVED WITH ADAPT?
IF YES, WHICH LOCAL GROUP ARE YOU PART OF?
HOW LONG HAVE YOU BEEN INVOLVED?
WHAT KINDS OF THINGS DO YOU DO WITH THE GROUP?
IF YOU ARE NOT CURRENTLY INVOLVED, ARE YOU WILLING TO START PARTICIPATING WITH YOUR LOCAL CHAPTER, PRIOR TO ATTENDING THE SUMMIT?
DO YOU KNOW WHAT CHAPTER IS CLOSEST TO YOU?
IF YES, WHICH ONE?
IF YOU ARE NOT CURRENTLY PART OF ADAPT, WHY ARE YOU INTERESTED IN PARTICIPATING IN AN ADAPT TRAINING?
3. WHAT ARE YOU HOPING TO LEARN FROM THE TRAINING, AND HOW WILL YOU USE WHAT YOU LEARN IN YOUR LOCAL COMMUNITY?
DO YOU HAVE SOMEONE IN YOUR LOCAL COMMUNITY TO WORK WITH? WHO OR WHAT OTHER GROUP WOULD THAT BE?
4. ARE YOU INTERESTED IN STARTING OR TAKING A LEADERSHIP ROLE IN A LOCAL ADAPT GROUP IN YOUR COMMUNITY?
5. DO YOU KNOW WHAT NON-VIOLENT DIRECT ACTION IS?
6. PLEASE TELL US YOUR DEFINITION OF NON-VIOLENT DIRECT ACTION.
WHAT KINDS OF DIRECT ACTION HAVE YOU PARTICIPATED IN, IF ANY?
7. AT THE SUMMIT, YOU WILL CO-COORDINATE A NONVIOLENT DIRECT ACTION WITH YOUR FELLOW TRAINEES. ARE YOU WILLING TO PARTICIPATE IN THE DIRECT ACTION?
8. WHAT WOULD YOU DO IF YOU NEEDED SOMETHING, AND PEOPLE WHO HAVE THE POWER TO GIVE IT TO YOU TELL YOU “NO” ?
9. WHAT DOES TEAMWORK MEAN TO YOU?
10. IF YOU ARE SELECTED TO PARTICIPATE IN THE TRAINING, YOU WILL BE RESPONSIBLE FOR COVERING THE COST OF YOUR TRAVEL TO AND FROM CHICAGO AND SOME MEALS.
WILL YOU NEED HELP RAISING THIS MONEY?
WHAT WILL YOU DO TO HELP RAISE THIS MONEY?
WOULD YOU BE INTERESTED IN PARTICIPATING IN THE ADAPT FUN RUN FOR DISABILITY RIGHTS ON BEHALF OF THE ADAPT YOUTH SUMMIT TO RAISE FUNDS FOR THE SUMMIT?
YOU ARE DONE!!!
THANKS FOR YOUR INTEREST TO FREE OUR PEOPLE
WHEN YOU HAVE FINISHED, PLEASE ATTACH ANY EXTRA SHEETS OF PAPER OR ANY OTHER MATERIALS YOU MAY HAVE USED TO ANSWER YOUR SHORT ANSWER QUESTIONS AND MAIL THE WHOLE APPLICATION TO:
JOSUE RODRIGUEZ
7604 HERMOSILLO
EL PASO, TX 79915
OR YOU CAN E-MAIL YOUR APPLICATION TO: adaptyouthsummit@yahoo.com
(PLEASE MAKE SURE TO PUT ADAPT YOUTH SUMMIT APPLICATION ON SUBJECT LINE OF YOUR E-MAIL)
OR FAX YOUR APPLICATION TO JOSUE RODRIGUEZ TO
915-598-7781
(PLEASE MAKE SURE TO PUT ATTENTION: JOSUE RODIRGUEZ
IF YOU NEED THIS APPLICATION IN A DIFFERENT FORMAT, OR HAVE ANY QUESTIONS ABOUT THE APPLICATION PLEASE CALL JOSUE ASAP! CALL OR TEXT HIM AT 915-407-6245
DON’T HESITATE!!!! APPLY TODAY!!!!!
