2024 ABLE Roadshow Event Registration Form

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* 1. Name

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* 2. How do we reach you?

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 3. Do you have an existing ABLE account?

Yes

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* 4. What is your role?

Person with a disability

Family Member or caregiver

Service Provider

Educator

Other (please specify)

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* 5. Which event do you plan to attend?

Sorry! We don't have an in-person event scheduled at this time. Select this option to let us know you're interested.

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* 6. Do you have any questions or is there anything in particular you would like to learn more about during this session?

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* 7. Do you require any special accommodations?

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* 8. Is it alright for one of our staff members to reach out to you in advance of the event to confirm your registration?

Yes

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* 9. What is the best way to reach you?

Phone

We are under obligation by our federal grant requirements to ask the following demographic questions:

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* 10. What is your gender?

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* 11. What is your race or ethnicity?

American Indian / Alaska Native

Asian

Black or African American

Hispanic, Latino, or Spanish Origin

Native Hawaiian or Other Pacific Islander

White/Caucasian

Multiracial or Multiethnic

I prefer not to say

Another race or ethnicity, please describe below

Self-describe below:

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* 12. What is your geographical profile?

Urban

Rural

I prefer not to answer