Connecticut Age Well Collaborative

Daring Dialogue Participant Registration

Thank you for your interest in joining a Daring Dialogue!

Are you on the journey to disrupt ageism and ableism? A Daring Dialogue can help your community raise awareness, reduce bias, and achieve more — together. Daring Dialogues are community workshops designed to foster open and constructive communication. We bring together community members and local leaders to challenge assumptions about aging and disability and explore how our biases influence our thoughts and actions.

Which Daring Dialogue will be be attending?

Name * Required

Select your Municipality * Required

What city or town will you be representing at the Daring Dialogue? You must live or work in the city or town.

Job Title

Employer or Organization

Email * Required

Phone

Select your role in the community (check all that apply) * Required

Resident over the age of 65

Resident with a disability

Care partner of a person with a disability

Municipal Leader (Volunteer)

Municipal Leader (Employee)

Other

Birthday

Optional: Demographic data helps the Connecticut Age Well Collaborative recruit diverse participation and understand who will be participating in the workshop. The information will not be shared.

Are you a person with a disability?

Optional: Demographic data helps the Connecticut Age Well Collaborative recruit diverse participation and understand who will be participating in the workshop. The information will not be shared.

Prefer not to answer

Yes

Not sure

What is your race?

Optional: Demographic data helps the Connecticut Age Well Collaborative recruit diverse participation and understand who will be participating in the workshop. The information will not be shared.

Prefer not to answer

Asian

Black or African American

Hispanic/Latino/a/x

Native American

Native Hawaiian or other Pacific Islander

White

Multi-racial

What is your gender?

Optional: Demographic data helps the Connecticut Age Well Collaborative recruit diverse participation and understand who will be participating in the workshop. The information will not be shared.

Do you identify as a member of the LGBTQIA++ community?

Optional: Demographic data helps the Connecticut Age Well Collaborative recruit diverse participation and understand who will be participating in the workshop. The information will not be shared.

Prefer Not to Answer

Not sure

Yes

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