Event Registration Survey

Thank you for your interest in participating in Survive and Thrive, Emergency Preparedness for People with Disabilities webinar presented by LEAP.

Please fill out the information below to register before June 3 at 12 pm EDT. If you are a caregiver, family member, friend, professional, or just a curious observer, please register separately, so we have an accurate count of all participants. After you register, you will receive instructions for logging into the webinar.

Announcing: Survive and Thrive, Emergency Preparedness for People with Disabilities
Presented by: LEAP, Linking Employment, Abilities, and Potential, of Cleveland
Where: Webinar Series
When: June 3, 10, & 17 at 2 p.m. EDT

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* 1. Participant contact info:

First Name

Last Name

Address

City/Town

County (Ohio residents only)

State

ZIP/Postal Code

Cell Phone

Email Address

Home Phone (Only if no cell phone)

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* 2. Participant demographic info (answer only what makes you feel comfortable):

Age

Gender

Race/ Ethnicity

Employment Status

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* 3. Are you a person living with a disability?

Yes, go to question 4

No, go to question 5 or 6

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* 4. If you answered YES to question 3, do you have paralysis? (defined as a range of disabilities including conditions due to stroke, spinal cord injury, multiple sclerosis, cerebral palsy or any nervous system disorder, and any that result in difficulty or inability to move upper and lower extremities)

Yes

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* 5. If you answered NO to question 3, are you a caregiver, family member or friend of someone living with a disability?

Yes

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* 6. If you answered NO to question 3, are you a professional who works with people with disabilities?

Yes

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* 7. Which of the following best describes your thoughts about preparing for a disaster?

I have heard about preparing for a disaster, but never thought about doing it myself.

I am trying to decide whether I should prepare for a disaster.

I have decided I DO NOT want to prepare for a disaster.

I have decided I DO want to prepare for a disaster, but I have not started to do this yet.

I have decided I DO want to prepare for a disaster, but I have not finished doing so.

I have decided I DO want to prepare for a disaster, and I have finished doing so.

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* 8. Would you like to be notified about future community trainings offered by LEAP? (Your information will not be shared with any outside parties).

Yes