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AT:LAST, Inc Survey Form

Thank you for taking the time to fill out the Survey Form. The demographic information from this form will help us provide better community outreach services to you in the future.

Child's Age: County/City: Does child use A.T. Currently? YES NO

Nature of Child's Disability:

Is your child enrolled in an educational program? ( Public or Private) YES NO
If yes, are you aware of your school system's Assistive Technology Team? YES NO

Are you a member of a support group such as ARC, CHADD, or Autism Society? YES NO
If yes, please give the name of your group and group contact person's name and phone #

Would you like to be included on our mailing list for future training opportunities? YES NO

NAME
ADDRESS
City/State/ZIP
E-MAIL

Please call me about how I can help as a Co-op volunteer.
Best # and time to reach you: