Application for Services "*" indicates required fields 1General Information2Voter Registration Assistance3Services4CARES Act Questions5Rights & Responsibilities6Closing Questions Note: The following form is quite long because of all of the information we need to collect in order to begin providing services to you. At the bottom of every page, you have the option of saving your place and continuing later (within 30 days of starting).County*(required) Note: the majority of our services are only offered to citizens or residents of certain Alabama counties. Information & Referral Services can be provided to anyone, regardless of state or county residence.Choose a CountyBibbBlountCalhounCherokeeClayCleburneEtowahFayetteGreeneHaleJeffersonLamarPerryPickensShelbySt. ClairTalladegaTuscaloosaWalkerMy county is not listedWhat county do you currently live in?*Choose a CountyAutaugaBaldwinBarbourBullockButlerChambersChiltonChoctawClarkeCoffeeColbertConecuhCoosaCovingtonCrenshawCullmanDaleDallasDekalbElmoreEscambiaFranklinGenevaHenryHoustonJacksonLauderdaleLawrenceLeeLimestoneLowndesMaconMadisonMarengoMarionMarshallMobileMonroeMontgomeryMorganPikeRandolphRussellSumterTallapoosaWashingtonWilcoxWinstonAt this time, Disability Rights & Resources doesn't offer our full list of services in this county. If you want more resources, please contact the Disability Resource Network - Get Contact InformationAt this time, Disability Rights & Resources doesn't offer our full list of services in this county. If you want more resources, please contact the Independent Rights & Resources - Get Contact InformationAt this time, Disability Rights & Resources doesn't offer our full list of services in this county. If you want more resources, please contact the Independent Living Center of Mobile - Get Contact InformationDisability Rights and Resources is accepting applications for some services only from individuals residing in a limited number of Alabama counties. Information and referral service is available to all, regardless of state or county residence. All services are offered to residents of these counties: Bibb, Blount, Calhoun, Cherokee, Clay, Cleburne, Etowah, Fayette, Greene, Hale, Jefferson, Lamar, Perry, Pickens, Shelby, St. Clair, Talladega, Tuscaloosa, and Walker. If you do not live in one of the counties listed above or do not live in the state of Alabama, the only services we can provide at this time are Information & Referral services. If you don't live in one of the above counties but are a resident of Alabama and you need more assistance than we can provide through our Information & Referral services, please contact Independent Rights & Resources in Montgomery by visiting www.independentrandr.org or calling 334-240-2520 or contact the Mobile Independent Living Center by calling 251-460-0301.Name of Applicant*(required) First Last Address of Applicant*(required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HiddenWhich county? Select all phone number(s) which you would like to provide*(required) Home Phone Number Mobile Phone Number Work Phone Number Other Phone Number Home Phone Number*(required)Mobile Phone Number*(required)Would it be okay if we contacted you via text/SMS?*(required)(standard message rates may apply) Yes, it would be okay if you contacted me via text/SMS No, it would not be okay if you contacted me via text/SMS Work Phone Number*(required)Other Phone Number*(required)Description of Phone Number(optional) Would you prefer us video call you, as opposed to an audio-only phone call?*(required) Yes, I would prefer a video call No, I would prefer audio-only Which video software do you prefer?*(required) I prefer FaceTime I prefer Skype I prefer Zoom I do not have a preference Other Email Address of Applicant(optional) Enter Email Confirm Email Birth Date*(required) Month Day Year Age*(required)Gender*(required) Male Female Gender not listed If desired, please specify your gender(optional) Race/Ethnicity*(required) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White Hispanic/Latino of any race or Hispanic/Latino only Two or more races or ethnicities Not Known or Prefer Not To Say Disability*(required)If you choose to add multiple disabilities, please do so on multiple lines Add RemoveDescribe how your disability affects your ability to function independently in your home, community, or work:*(required)How did you hear about us?(optional) Living Arrangement*(required) I live in Assisted Living I am living with Family or Friends I live independently I live in a nursing home I have other living arrangements than what is listed Where does your income come from?(optional) My income comes from employment My income comes from Social Security My income comes from Supplemental Security Insurance (SSI) My income comes from Social Security Disability Insurance (SSDI) My incomes comes from more than one of the above. My income comes from none of the above sources If desired, please specify where your income comes from Are you paid on an hourly or annual basis*(required) I am paid on an hourly basis I am paid on an annual basis I am paid another way Hourly Pay*(required)Average Amount of Hours (per week)*(required)HiddenAverage Monthly Salary (Hidden)Annual Salary*(required) 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. Disability Rights and Resources is accepting applications for some services only from individuals residing in a limited number of Alabama counties. Information and referral service is available to all, regardless of state or county residence. All services are offered to residents of these counties: Bibb, Blount, Calhoun, Cherokee, Clay, Cleburne, Etowah, Fayette, Greene, Hale, Jefferson, Lamar, Perry, Pickens, Shelby, St. Clair, Talladega, Tuscaloosa, and Walker. If you do not live in one of the counties listed above or do not live in the state of Alabama, the only services we can provide at this time are Information & Referral services. If you don't live in one of the above counties but are a resident of Alabama and you need more assistance than we can provide through our Information & Referral services, please contact the resource center that services your county - Get Contact Information.Are you interested in finding answers to questions about living with a disability?(optional) Yes No Information and Referral: Find answers to your questions about living with a disability. Get information about disability rights, resources, groups or programs that may help you, a family member, or a business. This service is provided to all residents of Alabama.Learn MoreAre you interested in developing skills for independent living?(optional) Yes No Independent Living Skills:Learn the skills you desire to have to be independent everyday and/or to live on your own .You can pick the areas on which you want to work, like budgeting, cooking, running your home, communication, transportation, relationships, or even how to speak up for yourself.Learn MoreAre you interested in learning how to advocate for yourself?(optional) Yes No Advocacy: Learn how to advocate for yourself and have your voice heard while acting for change that offers equal opportunity for people with disabilities. We can help you contact your government officials, write letters or make phone calls ,travel to Montgomery for special events or just figure out how to stand up for your rights in your own life.Learn MoreAre you interested in building relationships with peers?(optional) Yes No Peer Support: Learn problem-solving solutions, share successes and build relationships with other individuals with disabilities who may share your needs/concerns. Learn about new topics, such as healthy living, couponing , and job skills, while making new friends and being part of a team.Learn MoreDo you need help moving from a nursing home into the community?(optional) Yes No Transition into the Community: Receive assistance relocating from an institution into your own place. Get help learning about the things you will need to be successful - such as finding housing, setting up utilities, and arranging and getting support from others.Do you need help staying in your own home so that you don’t have to go to a nursing home?(optional) Yes No Nursing Home Diversion: Help prevent entering a nursing home by identifying problems that threaten your independence and solutions that work for you.Learn MoreAre you between the ages of 14-21 and need help planning for the future?(optional) Yes No Youth Transition Services: Extra help for individuals 14-21 who are in school or have just exited school. Get help understanding your disability at any age, discovering what is important to you, and how to set goals for yourself.Learn MoreDo you need help making your home more accessible?(optional) Yes No Home Modification Services: We assist low-income home owners to make their homes more accessible.Learn MoreDo you live inside or outside Birmingham city limits?*(required) Inside Birmingham city limits Outside Birmingham city limits HiddenDo you need help getting a job?(optional) Yes No Employment Assistance: The Disability Rights & Resources Employment Network Program provides services that assist those receiving SSDI or SSDI, and between the ages of 18 and 64 to meet their employment goals while understanding how working will affect your benefits.Learn MoreHiddenWere you negatively affected by the COVID-19 pandemic?(required)If you answer "Yes," the green "Next" button below will take you to another page where you will be asked to describe how you have been affected by COVID-19. Yes No CARES Act Funding: If your needs are not being met or are not being sufficiently met due to COVID-19, you may be eligible for financial assistance through the Part C CARES Act program. The purpose of this program is to address the needs of individuals with disabilities and help them to access or reconnect with the services and support they need to remain safely in their communities. Needs may be related to a wide range of issues, including housing, transportation, personal assistance, assistive technology, employment, medical supplies, personal protective equipment, and more. To qualify, an individual must have a significant disability, meet certain income limits, live within the agency’s service area, and have a need that has not been met or sufficiently met due to COVID-19. All CARES Act participants must become a Disability Rights & Resources consumer. 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 InformationDo 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/IndividualPurpose(s) Add RemoveExpiration 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.MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do 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/IndividualPurpose(s) Add RemoveExpiration 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.MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Is the individual filing out this form the applicant named on Page 1?*(required) Yes No If we are unable to get in touch with the applicant, can we reach out to you?*(required) Yes No Name of Assisting Individual(optional) First Last How would you prefer to be contacted?*(required) Phone Email Phone Number(s) of the Assisting Individual*(required) Add RemoveEmail*(required) Unique IDCAPTCHA NameThis field is for validation purposes and should be left unchanged. 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