United Cerebral Palsy: Survey - I&R Survey (July 2008)

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UCP AffNet Entrance [password required]

I&R Survey (July 2008)

Please fill out the following information


*	First Name: Required
*	Last Name: Required
*	Email: Required
	Street 1:
	City:
*	State / Province:	State / Province: Required
*	ZIP / Postal Code: Required
	Yes, I would like to receive e-mail from United Cerebral Palsy, Life Without Limits
	Yes, I would like to receive postal mail from United Cerebral Palsy

Question - Not Required - How did you find UCP?
Please make up to 3 selections from the choices below.

	Web search
	Referral from healthcare if so, what type of provider?
	Word of Mouth (friend/acquaintance)

Question - Not Required - Healthcare referral provider type:

Question - Not Required - Other (How did you find UCP?):

Question - Not Required - Where do you typically go for information?
Please make up to 4 selections from the choices below.

	Internet
	Magazines/Books
	TV
	Radio

Question - Not Required - Other (Where do you typically go for information?):

Question - Not Required - Please Specify (Internet):

Question - Not Required - Please Specify (Magazines/Books):

Question - Not Required - Please Specify (TV):

10.

Question - Not Required - Please Specify (Radio ie. call letters or type):

11.

Question - Not Required - What are the top three websites you visit for information?

(Maximum response 255 chars, approx. 5 rows of text)

12.

Question - Not Required - Would you like to receive future information, via email, on the work we're doing to create a Life Without Limits for persons with disabilities?

Yes, Sign me up for your Life Without Limits Monthly Newsletter

13.

Question - Not Required - Would you like to be a part of our new (or future) online community where you'll have a chance to meet and exchange with other parents and caregivers experiencing similar situations?

Yes

© 2009 United Cerebral Palsy (UCP National)
1660 L Street, NW, Suite 700, Washington, DC 20036
Phone: 800-872-5827/202-776-0406 TTY: 202-973-7197 Fax: 202-776-0414
E-mail: ecoordinator(at)ucp.org