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Registration Form

This form registers you for online classes. These classes are only for people with disabilities. You cannot enter the classes unless you have submitted this registration and have agreed to the READ ME FORMS. All the information you submit will be secure and confidential. It will not be shared or used for any other purposes outside of REACH. REACH of Dallas requests this data as a requirement by our funding sources. After you are registered you may enroll in as many classes as you like. Once you are registered you will receive a direct link into your class via an email, no password/login required.

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Select a Service Choose Online Services Online Mentors Individual Advocacy Housing Issues Online Classes

Last Name First Name

Street Address City

State Choose a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutD.C.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code County

Phone Number (i.e. 0123456789)

Email

ReEnter Email

Sex Female Male

Marital Status Married Widowed Single Divorced Separated

Living Situation Alone With Family or friends Assisted living Institution other

Transportation Own vehicle Use a Driver Arrange transportation Use public transportation No accessible transportation

Referral Source

Date of Birth Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990           Age

Ethnic Origin
Please check only one:

White/Caucasian Black/African-American American Indian Asian Hispanic Other

Please list all Disabilities
List all disabilites here.

Check here if you are a Registered Voter

Check here if you want info on obtaining a voter registration

Check here if you are eligible for services from REACH due to having a disability

Check here if you want a REACH Brochure mailed to you

Check here if you have been a consumer of REACH before

Check here if you have read and understand the information in the READ ME FORMS* required

Yes No I wish to waive developing an Independent Living Plan of Action at this time OR
           Click here to develop an ILP by email.

After you submit this form, you will be notified by e-mail when it has been processed and you will be provided a link to gain access to the online classes enrollment form. Please allow 1-3 days for processing.