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MPower Me Workshop Registration Form
Use this form to register a Student to attend a free MPower Me workshop at The Arc of Northern Virginia.
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* Indicates required question
Email
*
Your email
Student First and Last Name
*
Your answer
What does Student like to be called?
*
Your answer
Who is registering this Student? Please provide your name, relationship to Student, your phone number, and your email.
Your answer
Who does the Student authorize to receive MPower Me communications, and how? Please provide name, relationship, and preferred contact information.
Your answer
Will any family members also attend the Workshop?
*
Yes, a parent figure
Yes, a sibling or peer
I'm not sure yet
No
Other:
Required
Please describe Student's current use of technology.
Advanced interest in everything related to technology
Mobile Technologies - phones, tablets, MP3 players
Computers - PC or Mac
Gaming systems - (e.g. Playstation, Xbox, Wii)
TV - streaming videos or music (e.g. Netflix, YouTube)
CDs, DVDs
Very limited
Other:
Please help us estimate Student's current level of self-determination.
*
Able to self-advocate - can clearly state needs and preferences to anyone, without prompting
Some understanding of needs and preferences, but struggles to communicate them
Little to no understanding of needs and preferences without being given choices or suggestions
Little to no opportunity to express needs or preferences
Other:
Required
MPower Me workshops offer opportunities to interact with peers and learn about improving independence. Which of the following would engage your Student the most?
Prompting (e.g. scheduled activities like taking meds, getting ready to go somewhere, etc.)
Checklists (e.g. names of people in the room, types of pets, days of week, etc.)
Priming/ preparing (e.g. watch a video about arriving to an appointment before doing it)
Self-reporting activities, feelings, opinions (e.g. emoticons, selfie pictures, video instructions)
Mobile device preferences (e.g. screen brightness, volume, alarms, narrated voice pitch)
Other:
Please describe your priorities or expectations for your Student's participation in the MPower Me workshop.
Your answer
Does your Student have any specific interests they like to talk about?
Your answer
Are there any sensitive subjects that upset the Student that you would like us to avoid if possible?
Your answer
Do you have any questions or comments for MPower Me at this time?
Your answer
A copy of your responses will be emailed to the address you provided.
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