2012-2013 Senior Family Support Project - Training Series (MetLife Grant)

Thank you for your interest in attending The Arc of King County’s Spring Workshop Series. Please fill out following demographic information to assist us in preparing for the workshop. Please contact Amanda Peterson at apeterson@arcofkingcounty.org or 206-829-7035 with any questions.

Question Title

* 1. Registration

Attendee Name(s) *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address:

Phone Number:

Question Title

* 2. Do you have a loved one with an intellectual/developmental disability?

Yes

Question Title

* 3. If yes, please describe in as much detail as you feel comfortable:

Question Title

* 4. Relationship to individual:

Question Title

* 5. How old is your loved one?

Question Title

* 6. Age of workshop attendee(s):

Question Title

* 7. What is your race/ethnicity?

Native American Heritage

African American

White European, Caucasian

Hispanic (Latino)

Asian, Asian American

Middle Eastern

Hawaiian Native, or Pacific Islander

Other

Do not wish to respond

Question Title

* 8. Do you need language or communication accommodations, such as interpreter?

Yes

Question Title

* 9. If yes, what type of communication or language accommodations?

Question Title

* 10. Which workshop(s) are you registering for?

April 6th 2013 - Taking Care of Me: Resources for Seniors

April 20th, 2013 - Just for Adult Sibs

May 18th 2013 - Facing the Future Together with LifeSPAN

Question Title

* 11. Would you like a copy of The Arc of King County’s future planning organizer?
Developed with families in mind, this binder serves as a tool to keep all of your most important information together in one place and tool to begin planning for the future.

Yes

Question Title

* 12. Please remind me about the workshop(s) I’ve registered for one week prior to the event via

Telephone Call

Question Title

* 1. Registration

Question Title

* 2. Do you have a loved one with an intellectual/developmental disability?

Question Title

* 3. If yes, please describe in as much detail as you feel comfortable:

Question Title

* 4. Relationship to individual:

Question Title

* 5. How old is your loved one?

Question Title

* 6. Age of workshop attendee(s):

Question Title

* 7. What is your race/ethnicity?

Question Title

* 8. Do you need language or communication accommodations, such as interpreter?

Question Title

* 9. If yes, what type of communication or language accommodations?

Question Title

* 10. Which workshop(s) are you registering for?

Question Title

* 11. Would you like a copy of The Arc of King County’s future planning organizer? Developed with families in mind, this binder serves as a tool to keep all of your most important information together in one place and tool to begin planning for the future.

Question Title

* 12. Please remind me about the workshop(s) I’ve registered for one week prior to the event via

* 11. Would you like a copy of The Arc of King County’s future planning organizer?
Developed with families in mind, this binder serves as a tool to keep all of your most important information together in one place and tool to begin planning for the future.