2022 Virtual Leadership Summit Application

Virtual Event will be held on February 26, 2022

APPLICATION DEADLINE EXTENDED!!

Applications have to be submitted or postmarked by January 31, 2022

Name:  (First)      		(M.I.)       		(Last)      
Gender:         Birth Date        Race (Optional)        T-Shirt Size       
Email Address      
Mailing Address      
City      				 Zip      	County      
Phone      	
Current Grade      		Expected Graduation Date      
High School      		  	School Phone      
Parent / Guardian        	Phone      			Parent Email      

Please check the ones that apply:

How did you learn about the Forum? 

 School  	 Friend   Internet/E-mail/Social Media	 Transition Event  Other      

I am a Vocational Rehabilitation (VR) or Rehabilitation Services for the Blind (RSB) Client   

  Yes     No     Don’t Know 

I am a DMH Regional Office client.     Yes     No     Don’t Know

Have you participated at your local Center for Independent Living (CIL)?                       
	
  Yes     No     Don’t Know

Please describe your disability –
Primary Disability (medical diagnosis):        	Onset of Disability (age):      
Please check all that apply: 
Deaf / Hard of Hearing:
  I use sign language 
  I use assistive listening devices
  I use real time captioning
  I use lip reading
  I need interpreter services
  I use note takers
Blind / Visually Impaired:
  I read with Braille
  I read with large print
  I need assistance with mobility
  I prefer electronic format
Mobility Disability (e.g. spinal cord injury, muscular dystrophy, other):
  I use a wheelchair / scooter
  I cannot walk upstairs
  I use a walker, cane, or crutches
  I cannot walk long distances
Immune Disability:
  Crohn’s Disease
  Rheumatoid Arthritis
  Sickle Cell Anemia
  Other      
  Autism
  Asperger’s syndrome
  Traumatic Brain Injury
  Down Syndrome
  Intellectual Disability
  Mental Health Disability (e.g. anxiety,     depression, bipolar/mood disorder, obsessive compulsive disorder, other)
  Neuro/Muscular Disability
  Learning Disability (e.g. dyslexia, dyscalculia, ADD/ADHD, other…)
        Reading   Math   Written
  Multiple Disabilities
  Chronic Illness (e.g. cancer, cystic fibrosis, diabetes, heart disease, other)
  Chemical / Environmental Sensitivity
  Other (describe)      


Please list all accommodations needed to participate (interpreter, captioning, etc.) 
     








If unable to submit online you may email, fax, or mail your documents to:

Governor’s Council on Disability
Missouri Youth Leadership Forum
PO Box 1668
Jefferson City, MO  65102
rachel.rackers@oa.mo.gov
http://disability.mo.gov
Phone: 800-877-8249
Fax: 573-526-419