Training Application
Becoming Leaders for Tomorrow (BLT)
Please return to Al Romeo,
Name (Print): ______Date of Birth: ______
Street Address: ______
City: ______State: ______Zip: ______
Phone #: ______or TTY: ______
E-mail: ______
Name of School (If applicable): ______
If in school, what grade/year? ______
Do you have an IEP or 504 plan in school?
IEP: ____Yes ____No 504 Plan: ____Yes ____No
If employed, where? ______
If employed, what is your job title? ______
Are you currently on the waiting list for the Division of Services for People with Disabilities (DSPD)?
____No____Yes: date placed on waiting list ______
Have you ever been taken off of the waiting list for the Division of Services for People with Disabilities (DSPD)?
____No ____Yes: reason taken off list ______
The following questions on Cultural Diversity and Disability are optional. We are asking these questions in order to make sure that we are representing as many perspectives as we can. Your choice of whether or not to answer these questions will have no impact on your selection.
Gender: _____Male______Female
Race/Ethnicity
Page 1 of 2
_____Asian
_____Pacific Islander
_____Caucasian
_____Hispanic/Latino
_____Mixed racial background
_____African American
_____Native American/Alaskan tribe
_____Other
Page 1 of 2
Disability or Chronic Health Issues (mark as many as apply)
Page 1 of 2
_____Motor/mobility
_____Hearing
_____Visual
_____Learning
_____Cognitive
_____Emotional/Behavioral
_____Communication
_____Sensory
_____Other
_____Decline to answer
Page 1 of 2
Do you have special dietary needs or require special accommodations to attend training events, such as an interpreter or wheel chair access?
_____Yes _____No
If yes, please describe the special accommodation you need: ______
____ I am requesting to attend a small-group training for youth and young adults.
I am interested in training about:
____ Leadership____ Advocacy ____ Social Skills____ Health Care
____ Employment ____ Education____ Other ______
We will contact you and other applicants to set up a convenient training time for the group.
Applicant (youth/young adult) Signature: ______
If under 18 years of age or has a guardian:
Parent/Guardian’s Name: ______
Street Address: ______
City: ______State: ______Zip: ______
Phone #: ______E-mail: ______
Parent/Guardian signature for consent to attend training: ______
What is the best time of day to contact you?
Between ______and ______or ______
Do you have a computer and internet connection at home?
____No ____Dial-up____Cable or DSL
Do you have regular access to e-mail?
____Daily____Weekly____Monthly____No e-mail
How do you want to get information?
____E-mail____Postal mail____Telephone
Please send both pages of this application to Al Romeo at ; fax to 801-584-8488; call for assistance at 801-584-8535; or mail to:
Alfred Romeo
Utah Department of Health, CSHCN
PO Box 144610
Salt Lake City, UT84114-4610
Thank you!
Becoming Leaders for Tomorrow (BLT) Project, 2009,
Page 1 of 2