Community Accessibility - Community of Practice Interest Form

Thank you for considering to be a part of our Community of Practice! If you have any questions or concerns about this interest form, need assistance filling out this form, or want to request more information about the Community of Practice, please contact our Disability Initiatives Specialist, Connor Zielinski, at czielinski@lifeworks.org or 612-398-1967 (call or text).

This work is supported by the State of Minnesota Department of Human Services – Disability Services Division.

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* 1. Name

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* 2. Email and/or Phone Number

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* 3. Which primary perspective group are you interested in joining as?

Person with a disability/disabled person

For-profit business

Nonprofit organization

Disability services provider or disability advocacy organization

Other (please specify)

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* 4. What are you hoping to contribute to this project?

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* 5. What are you hoping to gain from this project? (gain new skills, contribute to inclusion efforts, networking opportunities, etc.)

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* 6. The Community of Practice will convene from April 2025 - June 2026. Are you able to commit to this?

I can commit for the full period of time

I can commit to some of the time

I cannot commit to the full period of time

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* 7. The Community of Practice will regularly meet April 2025 - June 2026. How often would you prefer to meet?

Monthly

Every other month

Quarterly (once every three months)

I have no preference

Other (please specify)

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* 8. Do you prefer meeting in person or virtually?

In person

Virtually

I have no preference

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* 9. We are exploring the potential to offer incentives for participation in this Community of Practice. Do any of the following interest you?

Free disability inclusion training offered by Lifeworks

Reduced cost accessibility consulting and training offered by Lifeworks

Gift cards

Check written to participant

Donation to a nonprofit of your choice

Other (please specify)

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* 10. Do you have any questions about the Community of Practice?

Below are all optional questions that ask you to disclose demographic information, including age, disability status, race/ethnicity, and geographic location. This information is requested by the grant this project is funded by and is worded per the grantor and does not necessarily reflect how Lifeworks views or collects demographic information. If you are not comfortable providing this information, please feel free to skip these questions. If you have questions or concerns, please contact our Disability Initiatives Specialist, Connor Zielinski, at czielinski@lifeworks.org or 612-398-1967 (call or text).

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* 11. What is your age?

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* 12. Are you a person with a disability? If so, please select the options below that best describe your disability.

Alzheimer's or Dementia

Brain Injury

Intellectual or Developmental Disability

Mental Illness or Mental Health Diagnosis

Physical disability

Other type of disability (specify only if you are comfortable doing so)

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* 13. What is your race/ethnicity?

African (not Black or African American)

American Indian or Alaska Native

Asian

Black or African American (not African)

Hispanic or Latinx

Native Hawaiian or Pacific Islander

White

More than one race or ethnicity

Other race/ethnicity (specify only if you are comfortable doing so)

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* 1. Name

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* 2. Email and/or Phone Number

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* 3. Which primary perspective group are you interested in joining as?

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* 4. What are you hoping to contribute to this project?

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* 5. What are you hoping to gain from this project? (gain new skills, contribute to inclusion efforts, networking opportunities, etc.)

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* 6. The Community of Practice will convene from April 2025 - June 2026. Are you able to commit to this?

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* 7. The Community of Practice will regularly meet April 2025 - June 2026. How often would you prefer to meet?

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* 8. Do you prefer meeting in person or virtually?

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* 9. We are exploring the potential to offer incentives for participation in this Community of Practice. Do any of the following interest you?

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* 10. Do you have any questions about the Community of Practice?

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* 11. What is your age?

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* 12. Are you a person with a disability? If so, please select the options below that best describe your disability.

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* 13. What is your race/ethnicity?

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* 14. What Minnesota county or tribal nation do you live in?