Virtual Insight Panel application
Please tell us more about you. Fields marked with an asterisk (*) are required.
Contact Information
First name
*
Middle name
Last name
*
Birthday
*
Gender identity
*
Female
Male
Non-binary
Prefer not to disclose
Address street 1
*
Address street 2
Address street 3
City
*
State/province
*
Zip/postal code
Email
*
*Note: You need to have an email address to submit a VIP application because we communicate about the upcoming activities through email.
Primary phone
*
Preferred contact method
*
Any
Email
Phone
Mail
About Me
Choose all that apply (must select at least one)
I have a disability
I am a family member who supports a person with a disability
Relationship to person I support
Parent
Sibling
Daughter/Son
Other Relative
Birthday of person I support
I am a legal guardian who supports a person with a disability
I identify with the following disabilities (for myself or my family member)
Choose all that apply (must select at least one)
Autism spectrum
Blindness/low vision
Brain injury
Chemical dependency
Chronic health condition
Chronic health condition comments
Deaf or hard of hearing
Developmental disability
Intellectual disability
Learning disability
Mental health
Physical or mobile disability
Speech or language disability
Temporary disability
Other disability
Other comments
I identify with the following race/ethnicities
Choose all that apply (must select at least one)
Non-Hispanic White, European or Euro-American
Black, Afro-Caribbean, African or African-American
Hispanic, Chicano or Latino
Asian and Pacific Islander
Middle Eastern or Arab-American
Native American, American Indian or Alaskan Native
Prefer not to disclose
Other
Preferred language
*
English
American Sign Language
Amharic
Arabic
Burmese
Cantonese
French
Hmong
Karen
Khmer
Karen
Lao
Oromo
Russian
Somali
Spanish
Vietnamese
Do you need an interpreter?
Programs/services/tools I have used or am using
Choose all that apply (must select at least one)
Disability Hub MN (formerly Disability Linkage Line)
DB101.org (Disability Benefits 101)
Directsupportconnect.com
HB101.org (Housing Benefits 101)
HCBS waiver
CAC
CADI
BI
DD
Home Care (PCA, Home Health Aide, Home Care Nursing)
MinnesotaHelp.info
Program HH/ADAP (AIDS Drug Assistance Program)
Self-Directed Services (CDCS, CSG, FSG)
Senior LinkAge Line
State Services for the Blind (SSB)
LinkVet
Vocational Rehabilitation Services (VRS)
No programs/services/tools used or am using
Types of activities that you want to participate in
Choose all that apply (must select at least one)
Focus groups in person
Focus groups with online presentation
Focus group phone conferences
Interview phone conferences
Interviews in person
Interviews with online presentation
Surveys/polls
Technology
Choose all that apply (must select at least one)
Computer/tablet in home with internet/email
Computer/tablet in home but not internet
Internet/email in a public space
Smart phone with internet/email
Smart phone without internet/email
Telephone
Referral
Did a VIP member refer you to apply for the VIP?
No
Yes
Referral first name
Referral last name
Terms and Conditions
I agree to the terms and conditions
*
*
Please select at least one about me option.
*
*
Please select at least one disability you identify with.
*
*
Please select at least one ethnicity or choose prefer not to disclose.
*
*
Please select at least one in any programs services or tools.
*
*
Please select at least one type of activity you want to participate in.
*
*
Please select at least one technology used.
*