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Thursday, July 02, 2009

Sign Up: STEP 1 of 2:
Your name and address is an important part of your message. It lets your legislator know that you are a potential voter and a person willing to stand up and be counted. It also lets us send your message to your legislator, even if you don't know who that is. Remember, you only need to sign up once.

** Conditions listed are NOT intended as labels for individuals.

* = required field
First Name:*
Last Name:*
Home Address:*
Home Address line 2:
City*
State:*
Zip Code:*
Phone:
Email Address:*
Work/organization name:
Work Address:
Work City State Zip:
Work Phone:
Cell Phone:
Fax:
School District:
Relationship to people with disabilities
	Individual with disability Family member Service provider Educator Direct Supports Staff Other
Year of birth of person with disability:
Best way to contact you with timely information?
	Home address Work address Email Fax Home phone Work phone Cell phone Morning Afternoon Evening Weekend Anytime Postal Mail Phone
I am most concerned with issues related to:**
	All Issues Autism Blind/Visual Impairments Brain Injuries Cerebral Palsy Cognitive Disabilities Communication Disorders Deaf/Hearing Impairment Developmental Disabilities Emotional Disabilities Genetic/Rare Disorders Learning Disabilities Mental Health Mental Retardation Physical Disabilities
I am most interested in the following topics:
	All Topics Assistive Technology Brokerage Services Child Care Community Services Early Intervention/Early Childhood Special Ed Employment Family Advocacy Family Support Health Care Housing Recreation Residential Supports Respite Care Self Advocacy Self Determination Special Education Transition from School Transportation
Other Primary Interest:
Ethnic/racial identity (OPTIONAL)
	African American/Black Alaskan Native/American Indian Asian Caucasian/White Hispanic/Latino Multiracial/Multicultural Pacific Islander/Native Hawaiian Russian/other East European Other
	Send me The Oregon Clarion
	Send me The People First Connection
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Enter the Password again:*	(4-12 characters)

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