Accessibility Committee Intake Form

Name *

First

Last

Email *

Role in SelfDesign *

Learner
Parent
Worker

Are you a resident of British Columbia? *

Yes
No

Because we need to achieve levels of representation on the Committee established by law, answering the following questions will assist us in making selection decisions based on these requirements.

While this information is helpful to us, it is not mandatory.

Are you any of the following? (please select any that apply)

A person with a visible or invisible disability; including physical, cognitive, perceptual, and/or mental health disabilities.
A member of a disability-serving organization
A parent or guardian supporting someone with a disability
A person with Indigenous background
A person from another equity-deserving group

Please provide the name of the disability-serving organization

If you are any of the above, can you please provide more information (optional)

Why do you want to be part of this committee?

What related skills, knowledge, or experiences do you have that may benefit this committee?

What accommodations do you require, if any?