Meet Our Members Questionnaire

Thank you for your interest in creating a Meet Our Members profile. The goal of this initiative is to help others get to know a little bit about our members to make it easier for us to connect with one another. Our plan is to share a new member profile at the beginning of each month in our e-newsletter and/or in a Facebook post with your consent. This information will not be shared in any other context by our organization without receiving further consent from you.

Meet Our Members Questionnaire

Name*
First Last
Please provide a little information about the nature of your mobility impairment (e.g. "spinal cord injury, C5 incomplete," "spina bifida," "multiple sclerosis," "amputee, single leg, below the knee."*
Number of years with a mobility impairment:*
Please answer between six to eight of the questions below to be included in your membership profile:
If you could visit any place in the world, where would it be?
What show have you recently binge watched on Netflix, Hulu, Amazon Prime, etc.?
Who is the first person you call when something exciting happens in your life?
What is your favorite song at the moment?
What is your favorite ice cream flavor?
What is one thing most people do not know about you?
Name something on your bucket list.
What is the one store you could easily max out your credit card in?
What guilty pleasure do you enjoy way too much to ever give up?
Name an item that you cannot live without?
What was your first job?
What is one piece of advice you’d give to your younger self?
What is a hobby of yours?
More Information:
Sometimes shared experience can have a powerful, positive impact. If you would like to include a few sentences that tell more about your story, who you are, your interests, accomplishments, or your mobility impairment, please do so in the space provided here.
Profile Picture:*
- I would like to add a profile picture in order to share a friendly face for others to see along with my information. I will upload my preferred picture and consent to its use in conjunction with my member profile.
- I prefer not to include a picture with my member profile at this time.
Please upload your profile picture here, if you choose to have one.
Max. file size: 256 MB.
E-Newsletter Consent:*
- I consent to the use of the information provided in this member profile to be shared in an I AM e-newsletter.
- I do not consent to the use of the information provided in this member profile to be shared in an I AM e-newsletter.
Facebook Consent:*
- I consent to the use of the information provided in this member profile to be shared in a Facebook post.
- I do not consent to the use of the information provided in this member profile to be shared in a Facebook post.
Peer to peer support can be impactful, and there may be cases where individuals are looking for this type of support. Are you open to being connected with those individuals if an interest is expressed?*
- Yes, I am open to being connected with individuals for peer to peer support.
- No, I am not open to being connected with individuals for peer to peer support.
In case we need to reach out to you, please provide your contact information:
Email*
Phone*
CAPTCHA

Meet Our Members Questionnaire

Meet Our Members Questionnaire

Please answer between six to eight of the questions below to be included in your membership profile:

More Information:

In case we need to reach out to you, please provide your contact information: