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California A11y Network (CAN) Membership Request Form

Thank you for your interest in joining in the California A11y Network! Please Complete this form to request to join the Network.

Network members must serve in the capacity of ADA Coordinator or perform accessibility related work for the organization they represent, but are not required to have the formal title of “ADA Coordinator.”

To request assistance completing this form or materials in an alternative format, please contact:

  • Jan Garrett: JanG@ADAPacific.org
  • Gabriel Navarrette: GabrielN@ADAPacific.org

Please note - the information shared in this form may be made available to all members of the California A11y Network. Contact information for individuals who serve as the designated ADA Coordinator will also be shared with the Pacific ADA Center and published on the Pacific ADA Center ADA Coordinators webpage.
* Indicates required question
1.Name of entity you are employed by.
(Required.)
2.Type of entity you are employed by(Required.)
3.First Name
(Required.)
4.Last Name
(Required.)
5.Work Phone Number. Please use format: xxx-xxx-xxxx(Required.)
6.Work Email Address
7.Job Title(Required.)
8.Department Name(Required.)
9.Are you the designated ADA Coordinator for your entity? Answer "yes" if you serve as an ADA Coordinator for your entity or a division within your entity, even if you do not have the formal title of "ADA Coordinator".
10.Are you a department level ADA Coordinator for your entity?
11.If you are not the designated ADA Coordinator for your entity and not a department level ADA Coordinator for your entity, please provide a brief description of the accessibility related work you perform for your entity.