Request service - for someone else Before filling out this form, please know that we can only provide services to persons with disabilities. If you are not a parent of a minor with a disability, or the legal guardian of a person with a disability, we will not be able to talk with you about someone else’s disability rights issue. If you were planning to fill out this form on behalf of someone else, please let that person know that they will need to make the contact with us directly (unless you are the parent or guardian). First, we will ask questions about you (the person filling out this form). Then, we will ask you questions about the person whom you are contacting us about (referred to in this form as “person with disability”). The Disability Rights Center of Kansas (DRC) has a policy against discrimination. People of any race, gender, religion, disability, or age have a right to take part in DRC programs. People who do not speak English or are Deaf or Hard of Hearing have a right to take part in DRC programs. DRC provides free language interpreter services for those who need them. DRC provides ASL and other accommodations for those who need them. Just ask DRC for help. Your First Name Your Last Name Your Email Your Phone Number Your relationship to the person with a disability Use the CTRL key to select more than one option. ParentGuardianPayeeFriendRelativeOther The next questions will be about the person whom you are contacting us about. What disability or disabilities do they have? First Name of person you're contacting us about Last name of person you're contacting us about Address of person you're contacting us about City State No valueAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth DakotaNorth CarolinaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Email of person you're contacting us about Phone number of person you're contacting us about Gender of person you're contacting us about No valueFemaleMaleOther Prefer not to answer Race of the person that you're contacting us about No valueAlaskan NativeAmerican IndianAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderTwo or more racesWhitePrefer not to answer Ethnicity of the person that you're contacting us about No valueHispanic/LatinoNot Hispanic/Latino What is the age of the person that you are contacting us about? Does the person that you are contacting us about have any of the following? Use the CTRL key to select more than one option. GuardianConservatorDurable Power of AttorneyRepresentative PayeeNone of these or not sure If the person that you are contacting us about lives in a facility, what is the name of the facility where they live? Has the person that you are contacting us about ever been the victim of any of the following crimes? Check all that apply. It does not matter if the crime was reported to the police. Use the CTRL key to select more than one option. Adult Physical AssaultAdult Sexual AssaultAdult that was sexually abused/assaulted as a childArsonBullying (verbal, cyber, or physical)BurglaryChild physical abuse or neglectChild PornographyChild Sexual Abuse/AssaultDomestic and/or Family ViolenceDUI/DWI IncidentsElder Abuse or NeglectHate Crime: Racial/Regligious/Gender/Sexual Orientation/OtherHuman Trafficking: LaborHuman Trafficking: SexIdentity Theft/Fraud/Financial CrimeKidnapping (custodial)Kidnapping (non-custodial)Mass Violence (Domestic/International)Other Vehicular Victimization (e.g. Hit and Run)RobberyStalking/HarassmentSurvivors of Homicide VictimsTeen Dating VictimizationTerrorism (Domestic/International)Violation of a Court (Protective) Order What is your reason for contacting the DRC? How would you like DRC to help? What would you like to see happen? Is anyone else helping with this issue? If so, who? When is a good time for us to get back with you about this issue? Do you have any preferences on how we contact you (phone/email)?