Services

1 Name:

2 Address :
       

3 Phone: Fax:

   Email:

4 My interest in Cerebral Palsy is:

• I am an individual living with Cerebral Palsy and my age range is:

    18 - 30                          31 - 45
    46 - 60                          61 - 75
    76 and above

• I am a parent of an individual living with Cerebral Palsy and his/her age is:

     Birth - 3                                 4 - 6
     7 - 12                                    13 - 18
     19 - 25                                  26 - 35
     36 - 45                                  46 and above

• I am a family member of an individual living with Cerebral Palsy (please check the appropriate ones)

      Sibling (brother/sister)
      Grandmother / Grandfather
      Cousin
      Aunt / Uncle
      Other :

• I work with an individual who lives with Cerebral Palsy:

      Nurse
      Doctor
      Social Worker
      Therapist - type:
      Care Attendent
      Others:

• None of the above categories fit for me -- please explain: