empowering people with disabilities ·
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Deaf Empowerment Program
Employment Services
Sign Language Interpreting
SSI/SSDI Benefits Planning
Temporary Loan Closet
Youth Services
Career Camp
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CIL Day
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Emergency Preparedness Conference
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Mystery Trip Suitcase Party
We Vote Rally
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Our Purpose
Our Impact
Our Team
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Advocacy Update
Blog
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Strategic Plan
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Request Interpreter
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CONTACT US
PROGRAMS
COVID-19 Resource Page
Deaf Empowerment Program
Employment Services
Sign Language Interpreting
SSI/SSDI Benefits Planning
Temporary Loan Closet
Youth Services
Career Camp
ABOUT
EVENTS
CIL Day
Community Education
Emergency Preparedness Conference
Spirit of the ADA
Mystery Trip Suitcase Party
We Vote Rally
Holiday Meals
Full Calendar of Events
How We Help
Our Purpose
Our Impact
Our Team
Media
Advocacy Update
Blog
In the News
Strategic Plan
Consumer Survey
VOLUNTEER
DONATE
Request Interpreter
Request Equipment
CONTACT US
SERVICE REQUEST FORM
Please provide us with the following information.
I am interested in the following program(s)
*
Careers 360
Brooks Temporary Loan Closet
Ready to Achieve Mentoring Program
Deaf Consumer Program
Work Incentives Planning and Assistance
Florida Telecommunications Relay, Inc.
Interpreting Services
Youth Advisory Council
LUNCH BREAK Program
Other (please specify below)
Specify if you chose Other above
Additionally, I am interested in the following service(s)
*
Free Amplified Telephones
Free Lunch
Food Stamp Assistance
Housing Assistance
Interviewing Skills
Job Search and Application
Medicaid Application
Peer Counseling
Resume Writing
Self-Advocacy Assistance
Transportation Assistance
Understanding SSI/SSDI Benefits
Volunteering
First Name
*
Last Name
*
Middle Initial
*
Date of Birth
*
Home Street Address
*
Apt Number
*
City
*
State
*
Email
*
Home Phone
*
Cell Phone
*
Work Phone
*
Race
*
Native American
Hawaiian/Pacific Islander
Asian
Hispanic/Latino
Black or African American
White or Caucasian
Other
Gender
*
Male
Female
Not Specified
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Partnered
Are you a Veteran?
*
Yes
No
Are you registered to vote?
*
Yes, and I want to update my registration
Yes, and I do not want to update my registration
No, and I want to register
No, and I do not want to register
Employment Status
*
Unemployed
Sheltered
Supported
Transitional
Internship (unpaid)
Internship (paid)
Part-time (competitive)
Full-time (competitive)
Unemployed, Not seeking
Unemployed, Seeking
Retired
Never worked
Self-employed
Residence Type
*
Assisted living
Transitional
Group home
Home owner
Homeless
Independent
Institution
Lives with Parent(s)
Nursing home
Dependent- Family/Friends
Rent (subsidized)
Rent (unsubsidized)
Other
Disability Type
*
Cognitive
Mental/Emotional
Physical
Hearing
Vision
Multiple
Other
My disability substantially limits me from functioning independently in the following area(s):
*
Self-Care
Mobility
Education
Employment
Housing
Other
The services I am requesting will help me (check all that apply)
*
improve my ability to function in my family or community
maintain my ability to function in my family or community
obtain, maintain, or advance in employment
Submit
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Code of Conduct
Grievance Procedure
Client Assistance Program
Staff Directory
