Name *

First Name

Last Name

Phone

(###)

###

####

TDD/Videophone

(###)

###

####

Best way to reach me is by:

Phone

Email

Text

Best times(s) to reach me:

days

evenings

weekends

Saturday night / Sunday (not during Shabbat)

I can be a resource in the following areas:

Please check all that apply

Connection to Jewish community activities, organizations, or functions

Connection to caregiver support, child care, or respite care resources

Financial resources for Jewish families and individuals with disabilities and other special needs

Jewish-related genetics and heath care resources

Legislative advocacy

Religious/Jewish practices and resources specific to disability and/or inclusion

Inclusive recreation and camp resources within the broad Jewish community

Transition Resources, including Supported Employment and Supported Living Options

I can be a resource for personal support:

Parent-to-Parent

Peer-to-Peer

I can be a resource for Jewish Education:

Hebrew/Sunday School

Bat/Bar Mitzvah Prep

Adult Education

I can be a resource for Legal Support:

Wills

Special Needs Trusts

Conservatorship/Guardianship

Mediation

The following accommodations will help me participate in CID meetings and activities:

Please check all that might apply

Assisted listening device

Sign language interpreter

Braille

Large print

Physical access for a walker, wheelchair, or other physical needs

Special meals, e.g. kosher, food allergies, special dietary needs

Remote participation