Full Name (Required)

Organization Name (if applicable):

e-mail (Required)

Address (Required)

Home Phone/TTY: (Required)

Work Phone/TTY:

Exchange Program(s) and year(s) you participated (Required)

How long was your experience? (Required) A week  Two weeks  Three weeks  A month  2 months  Summer  Semester  A year  More than a year

May we provide the following information to other individuals interested in international exchange opportunities? (Required) Address  Work Phone  Home Phone  FAX  E-mail  Disability Info

Member of racial/ethnic minority community (optional) Yes  No

What is your heritage?

Disability (Required)

Reasonable accommodations and equiptment you used while abroad Augmented Communication Device  Braille  Cane  Crutches  Extra Time  Guide Dog/Service Animal  Laptop Computer  Large Print  Manual Wheelchair  Medications  Note Taker  Oxygen  Personal Assistant/Attendant  Power Scooter  Power Wheelchair  Prosthesis  Sign Language Interpreter  Transliterater  Walker/Rollator  Ventilator  White Cane  Other

If you checked other, please describe the accommodation provided.

Do you require information in alternative format? Braille  Large Print  Electronic text  Cassette Tape

What is your current employment position? Please describe your primary responsibilities and/or recent accomplishments. (Required)

What impact did your international exchange program have on you? (Required)

Please share any disability-related exchange survival tips .

What is your message to those interested in participating in an overseas exchange?

Can we contact you to speak on a panel, or at a conference, regarding your international experiences? (Required) Yes  No

Are there any other people with disabilities you know who would be interested in participating in our peer-to-peer network?