| Name:: |
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| Current Address: |
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| Apartment or unit number:: |
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| City, State Zip code |
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| Home Address (if different from above):: |
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| Apartment or unit number:: |
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| City,State Zip code: |
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| Date of Birth:: |
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| Primary Phone/TTY:: |
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| Other Phone/TTY:: |
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| Fax:: |
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| E-mail:: |
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| What is the best way to contact you?: |
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| Are you involved with ADAPT now?: |
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| If yes, which local group are you part of?: |
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| What kind of accommodations will you need to participate in the summit? Select all that apply:: |
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| If Large Print Materials were Selected what font size Do you need:: |
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| if you will be bringing a personal care assistant with you: |
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| OPTIONAL QUESTIONS: |
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| GENDER:: |
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| RACE OR ETHNICITY – Select all that apply:: |
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| What is your disability?: |
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| If you are selected to participate in the summit, you will be responsible for covering the cost of your travel to and from Chicago and some meals. Will you need help raising this money?: |
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| SHORT ANSWER QUESTIONS: |
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| 1. If you are part of a local ADAPT group, tell us how you are involved. How long have you been involved and what kinds of things do you do with the group?: |
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| 2. If you are not currently part of ADAPT, why are you interested in participating in an ADAPT training?: |
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| 3. Do you know what nonviolent direct action is? If yes, what kinds of direct action have you participated in (if any)?: |
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| 4. What are you hoping to learn from the Youth Summit and how will you use what you learn in your local community?: |
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| 5. Are you interested in starting or taking a leadership role in a local ADAPT group in your community?: |
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| 6. What would you do if you want or need something and the people who have the power to give it to you tell you “no”?: |
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| YOU’RE FINISHED!: |
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