Wisconsin Assistive Technology Advisory Council Application, F-02574 (12/2019)

Introduction/Contact Information

Thank you for your interest in joining the Wisconsin Assistive Technology Advisory Council.

Submission of this application of interest does not guarantee you will be appointed to the Council. Appointments are made based on vacancies and specific representation needs.

By completing and submitting this application you agree:

You are a consumer who uses assistive technology (AT), a family member or guardian representing a person who uses AT, or a professional who works with consumers on AT-related issues.
To provide guidance and direction related to AT products and services throughout Wisconsin.
To travel and participate in four one-day meetings per year at various locations throughout the state (travel expenses will be reimbursed). Some meetings may be held via video or teleconference.
To participate and share your time and expertise by serving and actively participating on one or more Council committee(s), in addition to attending the four quarterly meetings.

If you have any questions or need assistance completing this application, contact Laura Plummer at 608-514-2513 or laura.plummer1@dhs.wisconsin.gov.

If you would prefer to complete this form by hand, please view and print form F-02574 from the Department of Health Services forms library.

Contact Information *This question is required.

First Name *This question is required.

Last Name *This question is required.

Street Address *This question is required.

City *This question is required.

State *This question is required.

Zip Code *This question is required.

County *This question is required.

Daytime Phone Number *This question is required.

Email Address *This question is required.