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Title:
Ms
Mrs
Mr
Jr
Sr
First Name:
Last Name:
Gender:
Male
Female
Do You Have Disability?:
Yes
No
If Yes, Please Indicate:
Addiction (alcohol or other drug)
Chronic disease (example: diabetes, multiple sclerosis)
Developmental disability
Hearing Impairment
Medical services (example: dialysis)
Mental health
Physical disability
Sight Impairment
Other
Age:
0-17
18-30
31-40
41-50
51-60
61 and over
Contact Information:
Street Address:
Apt. #:
County:
None
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Allegheny
Armstrong
Beaver
Bedford
Berks
Blair
Bradford
Bucks
Butler
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Centre
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Forest
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Indiana
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Montour
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Perry
Philadelphia
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Potter
Schuylkill
Snyder
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Union
Venango
Warren
Washington
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Wyoming
York
State:
Alabama
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Idaho
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Iowa
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South Carolina
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Tennessee
Texas
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Virginia
Washington
Washington D.C
West Virginia
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xxx
xxxx
City:
ZIP Code:
Location:
Urban
Rural
Cell:
Home:
Work:
E-mail:
Contact Preference:
Cell
Home
Work
E-mail
Services Used:
Affiliations:
Bureau of Blindness and Visual Services (BBVS)
Center for Independent Living (CIL)
Office of Vocational Rehabilitation (OVR)
Personal Assistance Services (PAS)
Social Security Disability Insurance (SSDI)
Supplemental Security Income (SSI)
Medicaid
Housing
Assistive Technology
Other
None
Aging and Disability Resource Center (ADRC)
ARC
Center for Independent Living (CIL)
Community Living Advisory Committee (CLAC)
Disability Benefits Consortium (DBC)
Developmental Disability Council (DDC)
Disability Voting Coalition (DVC)
Governor's Committee on Employment of People with Disabilities (GCEPD)
Office of Vocational Rehabilitation (OVR)
Regional Action Team (RAT)
Statewide Independent Living Council (SILC)
Stakeholder Planning Team (SPT)
United Cerebral Palsy (UCP)
Other
Are You Registered to Vote:
No
Yes
US House
District:
-Select-
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
PA Senate
District:
-Select-
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02
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50
PA House
District
-Select-
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Issue Interests:
Accessibility
Assistive Technology
Disability Discrimination Issues
Disability Legislation
Employment
Health Care
Home and Community-based Services
Housing
Judiciary & Courts
Nursing Home Transition
Transportation
Vocational Rehabilitation
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Other
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