My Life, My Rights - Video Course Registration Upon completion of the application, you will be connected to the My Life, My Rights 8-module video course. Question Title * 1. Name: Question Title * 2. Enter contact information below: Address * Address 2 City * State * ZIP Code * County of Residence * Email * Phone Number * Question Title * 3. Preferred Mode of Contact: Phone Email Question Title * 4. Agency of Services: Please complete the following demographic questions which are required for reporting purposes: Question Title * 5. Date of Birth: _ Date Question Title * 6. Gender: Female Male Non-Binary Other (specify) Question Title * 7. Race/Ethnicity: (Please choose only one.) American Indian or Alaskan Native Asian Black or African American Hispanic White / Caucasian Multiracial Native Hawaiian or Other Pacific Islander Other (please specify) Question Title * 8. Do you associate with a disability: Yes No Question Title * 9. Please enter your social security number (with dashes) and/or your DMH ID number below. Social Security Number: DMH ID Number: Done