Application for Services

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1General Information

2Voter Registration Assistance

3Services

4CARES Act Questions

5Rights & Responsibilities

6Closing Questions

The National Voter Registration Act of 1993 (also known as the “NVRA” or “motor voter law”) sets forth certain voter registration requirements with respect to elections for federal office. Section 7 of the NVRA requires that States offer voter registration opportunities at certain State and local offices, including public assistance and disability offices. Please take a moment to complete the form.

Voter Registration Declaration Statement
If you are not registered to vote, we can provide a voter's registration application form to you.

We will assist you in filling out the form, or you may fill it out privately. Applying to register, or declining to register to vote, will not affect the amount of assistance that you will be provided by this agency.

Would you like to register to vote?*

I would like to register to vote

I am already registered to vote

I do not want to register to vote

I would like to restore my right to vote

Disability Rights & Resources currently does not offer services to assist individuals in restoring their right to vote. You may visit the Alabama Secretary of State's website for resources regarding restoring your right to vote.

Please describe in detail how the COVID-19 pandemic has affected you and how CARES ACT assistance will help.*

(required)

DRR Complaint Procedure and Client Assistance Program (required)*

While participating in any of our Independent Living Programs, it is important to have a way to let others know if you are having a conflict or are unhappy with the services you are receiving. The following procedure is designed to assist you in resolving problems.

These policies relate to a consumer, parent, or legal guardian. When the desires of the consumer differ from those of a relative, rights and wishes of the consumer shall take priority if the consumer has attained the age of majority.

Your right to an internal appeal with Disability Rights and Resources:

Step One: Tell the staff member that you are working with that you do not agree with the anticipated decision. Schedule an appointment with your staff member to discuss the problem or grievance and attempt to find a satisfactory solution..

Step two: If you are not satisfied, a conference can be scheduled with the supervisor of the program in which the consumer is a participant.

Step three: If no satisfactory solution is found a written request to bring the matter before the Executive Director may be submitted to the Executive Director. In such cases, a copy of the request must be provided to the supervisor of the program. Such requests shall include a detailed description of the problem and the course of action taken to that point.

Step four: Finally, a written request may be submitted to the President of the Board of Directors. A copy of this request shall be provided to the Executive Director. The Board President will select a committee of three representatives of the Board of Directors to review and make recommendations to the President. The decision is final.

If, at any time you feel you are in conflict with an anticipated action or decision from Disability Rights and Resources, you may request assistance from the State of Alabama Client Assistance Program - http://sacap.alabama.gov 800-228-3231.

I have received information concerning Disability Rights and Resources Complaint Procedure and State of Alabama Client Assistance Program. The purpose of the program and how to contact the program have been explained to me.

Statement of Rights And Responsibilities (required)*

Rights:
You have the right to be treated with dignity and respect. You have the right to privacy and confidentiality.
You have the right to live as you choose, in your own home, free from judgment or interference.
You have the right to make your own decisions.
You have the right to have materials provided in the format of your choosing.
You have the right to choose your own life goals toward independence and establish the timeframe to achieve your goals.
You have the right to change your mind about any advocacy, support, or goals.
You have the right to bring an advocate, friend, or family member to any/all meetings. You have the right to copies of all paperwork.
You have the right to file a grievance.
You have the right to file a complaint with SACAP.

Responsibilities:
I am responsible to take part in any services I ask for. This means attending meetings, classes, and trainings.
I will communicate with my staff member and direct my service delivery to help me to learn how to self-direct my own life.
I agree to meet with my staff member every 60 days.
If I must miss an appointment I will try to let my staff member know in advance.
I agree that if my staff member contacts me three times in a row or I miss three planned meetings in a row my case may be closed 10 days after receiving a contact letter.
I agree to complete a consumer survey.
I will treat all advocates and staff with dignity and respect.
I am responsible for my life goals and completion of the activities, achievements, and goals. I have read and understood these rights and responsibilities.

I have read and understood these rights and responsibilities.

Please type your full legal name:*

(required)

Release of Information

Do you want to authorize Disability Rights & Resources to release specific information to specific agencies/persons?*

Note: By answering yes, we will ask you to specify which agencies/individuals we can delete information to and what information can be released to them.

Yes, I authorize Disability Rights & Resources to release information to external agencies/individuals

No, I do not authorize Disability Rights & Resources to release any information to any external agencies/individuals at this time

Please list the names of the agencies/individuals that we can release information to and the purposes of these releases (if specific):

(Leave the "Purpose" column if you want to give Disability Rights & Resources broad authority to release information)

Agency/Individual

Purpose(s)

Expiration Date of Release

(optional) Specify an expiration date if you would like this release authorization to expire. Note that, at any time, you can extend this authorization or re-authorize Disability Rights & Resources to release information. On or before this date, Disability Rights & Resources will ask if you would like to extend your release authorization.

Do you want to authorize external sources to release information to Disability Rights & Resources?*

Yes, I authorize the above sources to release information to Disability Rights & Resources for the specific purpose(s) detailed above

Yes, but I want to give details that differ from what I have provided above regarding which sources can release information to Disability Rights & Resources

No, I do not authorize any source to give information to Disability Rights & Resources at this time

Please list the names of the agencies/individuals that can release information to us and the purposes of these releases (if specific):*

(Leave the "Purpose" column blank if you want to give the specified source broad authority to release information to Disability Rights & Resources)

Agency/Individual

Purpose(s)

Expiration Date of Release

(optional) Specify an expiration date if you would like this release authorization to expire. Note that, at any time, you can extend this authorization or re-authorize external sources to release information to Disability Rights & Resources. On or before this date, Disability Rights & Resources will ask if you would like to extend your release authorization.

Is the individual filing out this form the applicant named on Page 1?*

(required)

Yes

If we are unable to get in touch with the applicant, can we reach out to you?*

(required)

Yes

Name of Assisting Individual

(optional)

First Last

How would you prefer to be contacted?*

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Phone

Phone Number(s) of the Assisting Individual*

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Email*

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Unique ID

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Comments

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The offices of Disability Rights & Resources are open. Services are available in-person or virtually by phone or email.

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