I AM Membership Update Questionnaire

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

We currently update members using the following formats. What is your preferred format?*

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We currently update members using the following formats. What is your preferred format?

Monthly E-newsletters
Text Updates
Social Media
Periodic Mailings

What is your second preferred format?*

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What is your second preferred format?

Monthly E-newsletters
Text Updates
Social Media
Periodic Mailings

As a chapter of United Spinal Assoc. They ask that we share our membership list with them to help their efforts to advocate and help improve the lives of those with disabilities. Do you mind if we share your contact info with them?*

Yes. I am okay with you sharing my information
No. I would prefer you do not share my information.

Please write what type of mobility impairment you have.*

How are you doing in general?*

How are you doing in relation to the circumstances related to COVID-19?*

How are you doing with social distancing?*

Are you interested in participating in virtual events?*

Yes, I am interested.
No, I am not interested

Do you have any recommendations for virtual events?

How do you feel about returning to in-person events? When, or under what circumstances do you think you would feel comfortable doing so?*

Are you aware of our Individual Relief Grant?*

Yes. I am aware of this grant.
No. I am not aware of this grant.

Are you aware of our Wellness Grant?*

Yes. I am aware of this grant.
No. I am not aware of this grant.

Do you have any questions about the Individual Relief Grant or the Wellness Grant?

We are working on creating an adaptive rowing and kayaking club in addition to our regular cycling events. Are either of these something you would be interested in? Please click all that apply.*

I am interested in an adaptive rowing club.
I am interested in an adaptive kayaking club.
I am interested in cycling events.
I am not interested in any of these.

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We are working on creating an adaptive rowing and kayaking club in addition to our regular cycling events. Are either of these something you would be interested in? Please click all that apply.

I am interested in an adaptive rowing club.
I am interested in an adaptive kayaking club.
I am interested in cycling events.
I am not interested in any of these.

We are putting together an About Me section for our newsletter and possibly Facebook to help others get to know our members and connect with each. Would you be interested in taking part in this and sharing a bit about yourself? If you select yes, we will reach out you with further details.*

Yes. I am interested in taking part in this.
No. I am not interested in taking part in this.

Do you have any suggestions on how I AM can be helpful?*

Are there any programs/activities you would like to see created?*

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I AM Membership Update Questionnaire