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Disability Rights of West Virginia
Board of Director’s Biographical Data Sheet
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Primary Interest

For Federal grant documentation and report purposes, please check all that apply:

Gender
Ethnicity
Are you a person with a disability?
If so, what is/are your disability(ies)? (Please check all that apply)
Are you a guardian of a person with a disability?
If so, what is/are their disability(ies)? (Please check all that apply)
If the person for who you are a guardian is eligible for services, what age is that person who is eligible? Check all that apply
Do you have a family member who has a disability?
If so, what is/are the family member's disability(ies)? (Please check all that apply)
If your family member is eligible for services, what age is that person who is eligible? (Check all that apply)
Are you a professional in the field of… (Please check all that apply)
Are you a service provider for persons with… (Please check all that apply)
Are you an advocate for persons with… (Please check all that apply)
Are you an Attorney?
Are you an individual from the public knowledgeable about… (Please check all that apply)
Are you a person who broadly represents or is broadly knowledgeable about the needs of people with… (Please check all that apply)
Are you a Board Member or Advisory Council Member for a provider of services to Individuals with Disabilities?

Thank you for applying! We'll get back to you soon.

5088 Washington St. W,
 Suite 300

Charleston, WV  25313

Office Hours

Monday - Friday:  8:30 am - 4:30 pm

1-800-950-5250

(304) 346-0847

(304) 346-0867

Acknowledgement:  The following federal authorities share in the cost of funding this website:  The U.S. Department of Health and Human Services, Administration for Community Living (ACL) and the Substance Abuse and Mental Health Services Administration (SAMHSA); the U.S. Department of Education, Rehabilitation Services Administration (RSA); and the U.S. Social Security Administration (SSA). Although SSA reviewed certain publication for accuracy, it does not constitute an official SSA document. The contents do not necessarily represent the official views of ACL, SAMHSA, RSA, SSA, or any other funder. We developed this website at U.S. taxpayer expense.

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