What is your relationship to an individual with an intellectual or developmental disability? *

Self

Parent/Guardian

Sibling

Friend

Other (please specify below)

Would you be interested in starting/joining a support/information group or groups concering intellectual and developmental disabilities? *

Yes

No

Which day(s) of the week would be most convenient for you in order to meet? *

Select all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

No Preference

What time(s) of the day would be most convenient? *

Select all that apply.

Morning (8-12 am)

Afternoon (12-3 pm)

Evening (3-6 pm)

Night (6-9 pm)

No Preference

What type of support group are you looking to join? *

Select all that apply.

Coping Skills/Problem Solving

Educational Resources

Emotional Support

Financial Support

Future Planning

Legal Information

Legislative Information

Medical Information

Relationships and Boundaries

Specific Disability Support (list below)

Other (list below)

Any/No Preference

Would you like to have professionals/specialists come as guest speakers to the support groups on occasion? *

Yes

No

No Preference

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Preference *

How would you prefer The Arc get in touch with you about future meetings?

Phone

Email

Mail

No Preference