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'Empowered' Application Form

Please enable JavaScript in your browser to complete this form.

Name: *

First

Last

Date of Birth: *

Phone Number: *

Email: *

Address: *

Current Occupation: *

Current Situation: *

I have a dream/goal.
I've achieved some pretty cool dreams/goals, but I don't know what the next dream/goal looks like.
I'm a little bit stuck in life, but motivated to become unstuck and set an awesome dream/goal.
I'm a little bit stuck in life, I'm not motivated at all to change, and I don't care about dreams/goals.

What is your dream/goal?: *

What/who in life motivates/inspires you?: *

What are you most proud of out of your accomplishments?: *

Which of the following best describes how you view your disability?: *

I consider my disability as something that defines me.
I consider my disability as something that is just a part of many things that make me who I am.
I consider my disability as my superpower.
I consider my disability as something that I barely notice, but other people notice it.
I consider my disability as something that I notice all the time, but others barely notice it.
Other.

Please explain how you view your disability: (if selected other):

What do you hope to get out of the Empowered Program?: *

Do you prefer group training or one-on-one?: *

Group Training
One-on-One

Is there anything that stops you from traveling or staying in a hotel?: *

No
Yes

Please explain what stops your from traveling or staying in hotel (if selected yes):

Is there anything else you want to tell us or that we need to be aware of?: (This could include mobility issues, support requirements, previous experiences with programs, etc.)

About Us
- Values
COMMITTEES
- National Committee
- Auckland
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- Waikato
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Programs
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Events
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News
Contact

About Us
- Values
COMMITTEES
- National Committee
- Auckland
- Wellington
- Waikato
- Dunedin
- Canterbury
- Manawatū
- Alumni
Programs
Report Cards
- Report Cards 2024
- Report Cards 2025
Events
Blogs
News
Contact

Yes Disability Resource Centre
Email: ilead@yesdisability.org.nz
Phone: (09) 414 5360
PO Box 301 397, Albany

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