MYLF Mini Registration

Please select the MYLF Mini even that you wish to attend
Last Name
First
Middle
Address
City
Zip
Male / Female
Phone
Name of High School
Grade Level
Your E-Mail Address
Birth Date
Date Graduation Expected
Social Security Number OR School ID Number
Your Ethnicity
Please describe your disability. This information will assist in assuring that we include delegates with a diversity of disabilities.
Disability (medical diagnosis)
Onset of disability
Check all that apply:
Deaf
Hard of Hearing
   I use sign language
   I use real time captioning
   I use lip reading
Other
Blind
Developmental Disability
Describe

Autism
Traumatic Brain Injury
Visual Impairment
   I read with Braille
   I read with large print
Mental Health Disability
Neuromuscular Disability
Learning Disability
Multiple Disabilities
Orthopedic Disability
   I use a wheelchair
   I cannot walk upstairs
   I cannot walk long distances
Other Disability
Details