Date

First Name

Last Name

Email Address

Phone

Address

How did you hear about Donka? How did you hear about Donka?Internet SearchAdFlyerCalled DonkaWalked inReferred by Individual

If referred by an individual, please let us know If referred by an individual, please let us knowCommunity agency providerDonka staff memberIL Department of Rehabilitation Counselor

What is your disability What is your disability Physical Visual Learning Other

Other Disability

What type of training are you interested in What type of training are you interested in Microsoft Office Skills Assistive Technology iPad, iPhone apps Social Media Job Readiness