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New York Disability Vote Network

Individual Signup :: Please complete the form below

* Denotes a required field.

All information gathered will remain with the Center for Disability Rights and ACCES-VR and not shared with third-party entities.

Are you a person with a disability?	Yes No
First Name*
Middle Initial
Last Name*
Gender
Party Affiliation
Street Address
Address Line 2
City
Zip Code
Who referred you to NYDVN?
Email Address
Phone	Your primary contact number
Cell Number
Disability-related issues important to voter:	Housing Transportation Voting Access Communication Access Expansion/Enforcement of ADA Long-term Services and Support
How Often do You Vote?
What accommodations do you require to vote?	Absentee voting Accessible parking Curbside voting Voter assistance Wheelchair-friendly voting stations Larger stylus for punch-card Braille sleeves Audio tape other:
By submitting this form, you will also be added to the NYDVN mailing list. We will keep you informed on important voting information and events via email.*

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