Disability Education and Etiquette Registration

Presented by Connections Access Consulting Services, LLC

By submitting this form, you are granting our agency permission to retain your personal information for the purpose of contacting you and/or providing services to you. View our Privacy Policy here.

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
The following information is kept confidential and is requested only for the purpose of insuring that the class sessions are diverse.
Age:*
Gender:*
- Male
- Female
Indicate why you are interested in enrolling in CACS’s Disability Education and Etiquette program:
What do you hope to gain or learn from participating in the Disability Education and Etiquette program?
Describe your involvement with the disability community and/or other community/civic activities:
How did you hear about CACS’s Disability Education and Etiquette program?
Please share any accommodations you require.
- Braille Materials
- Large Print
- Taped Session
- Wheelchair Accessibility
- Note Taker
- Sign Language Interpreter
Additional Comments:
Cost of Registration*
Price:

Presented by Connections Access Consulting Services, LLC

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