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FAAST NW RDC

Register for Event

Name

I am a: *

Who is Submitting Registration?

First Name *

Last Name *

Email Address *

Phone Number *

Physical Address Line 1 *

Location data helps us get to know our audience

Physical Address Line 2

Location data helps us get to know our audience

City *

Location data helps us get to know our audience

State *

Location data helps us get to know our audience

Zip Code *

Location data helps us get to know our audience

County

Only fill if you are a resident of Florida

Number of Party Members Attending *

Names of each of the extra party members can be added on the next page of this form

Ethnicity

Primary Language is:

(Military Information) I am, or was, a member of

Fill in only if member of Military

Military Component

Accommodations Required

Language Interpreter (Language)

I or a member of my family am/are currently on a waiting list for services from a State Agency:

I/my children receive services through (check all that apply):

Agency for Persons with Disabilities

Children’s Medical Services (CMS)

Children’s Mental Health

Brain & Spinal Cord Injury Program

Department of Education, Division of Vocational Rehabilitation (current)

Department of Education, Division of Vocational Rehabilitation (past)

Exceptional Student Education (ESE)

Medicaid

Medicare

Department of Education, Division of Blind Services

CDC+ Waiver

Early Steps Program

Other (Please describe in the next field)

If Other, Please Describe

I/my family members am/are a Social Security Administration (SSA) beneficiary

How many family member(s) are SSA beneficiaries

If you/they are an SSA beneficiary, are you/they between the ages of 18-64 and receiving Supplemental Security Income (SSI) and/or Social Security Disability Income (SSDI)?

The success of The Annual Family Café relies on the help of our many generous volunteers. Please consider helping us out this year, by volunteering for one of the following:

If you want to volunteer as a Language Interpeter, what language can you interpret?

I Require Financial Assistance for (Only fill out if assistance is required)

In order to qualify, you must be a person with a disability or their family member residing in Florida, and you must live in a community that is located more than 50 miles from the City of Orlando. Funding will be distributed according to State of Florida guidelines. Applicants will be notified of their status by mail in April, 2020. NOTE: All Assistance is based on the availability of funding and awarded by lottery.

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