Membership Form

I am a:

Person with a mobility impairment who would like to join I AM.
Person without a mobility impairment who would like to join the I AM community.

Contact Information:

All personal information will be kept confidential for use within the organization and not shared with outside organizations or entities without consent. All privacy concerns will be respected.

As an affiliate of United Spinal Association we try to work together to enhance the lives of people with SCI/D. One of the ways in which we do this is by sharing information with United Spinal that will help better assess and understand the needs of the spinal cord injury community as a whole. This helps provide concrete data that is necessary to move forward with research, develop beneficial programs, and positively influence those who provide important services.

Please check here if you consent to share your information with United Spinal.*

I consent
I don't consent.

Personal Information

Name*

Prefix First Middle Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Address

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

Phone*

Phone

Email*

Please check all that apply:*

I am a family member of an individual with a mobility impairment.
I am a friend of an individual with a mobility impairment.
I am a healthcare professional.
I am a researcher.
I am a manufacturer/distributor of mobility products.
I am interested in volunteering with I AM.
Other.

If you selected Other to the question above, please describe your interest in the group.

Sex

Male
Female
Prefer not to answer.

Date of Birth:*

MM

DD

YYYY

Your Mobility Impairment:*

Year of injury or onset of mobility impairment.

Level of Function:*

Paraplegia
Quadriplegia
Hemiplegia
Difficulty grasping
Difficulty walking
Other

If you selected to question above, please indicate your level of function:

Are you a wheelchair user? Select all that apply.*

No
Part-time
Full-time
Manual Wheelchair
Power Wheelchair
Mobility Scooter
Other

If you selected other to the question above, please describe type of mobility assistive device.

Are you a veteran?*

Yes
No

Preferred method of contact

Please tell us where you heard about our group in order that we may recognize how we are succeeding in our efforts to reach others. For example: website, newsletter, etc.*

If there is other information you feel we should know or would like to share, please indicate below.

Group information

Please select all the different formats which you will use to stay updated on programs and events within our organization.*

E-newsletter
Monthly text updates/reminders
Facebook
Twitter
Instagram
Other

If you selected Other to the question above, please indicate how you would like to stay updated on programs and event withing our organization.

Do you wish to receive text updates about Individual Abilities in Motion?*

Yes
No

What would you most like to get out of this group? Please check any areas of interest.*

If you answered Other to the above question, please list what you would most like to get out of this group.

The following is a list of some possible activities. Please check any that you might be interested in.

Please list any specific ideas or additional suggestions regarding your areas of interest:

Does any particular day or time suit you best

Do you have any suggestion for raising funds to help in achieving our goals?

Please check if you are open to sharing your personal experience on a one-to-one basis
Please check if you would like to become involved in the peer-mentoring program

Please list any area in which you feel you are either willing, or able to contribute to Individual Abilities in Motion.

Please feel free to add any other thoughts, ideas, or comments. It is through your input, that we will make this a success.

Are you interested in information about local chapters of NSCIA?

Yes
No

I would like to be contacted in regard to questions I have related to Spinal Cord Injury/Disease and/or NSCIA.

Yes
No

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