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Are you, or is a member of your family disabled?   YES   NO 

How did you or your family member's disability occur?

 Auto Accident                    Born with disability       
 Violent Crime                    Sports Injury     
 Work related injury              Warfare
 Slip/Fall injury                 Health or Natural causes   

Please check your disability:

1 Post Polio             11 Hearing Impaired
2 Muscular Dystrophy     12 Vision Impaired
3 Heart Problem          13 Paraplegic
4 Cerebral Palsy         14 Quadriplegic
5 Spina Bifida           15 Incontinence
6 Head, Spinal Injury    16 Arthritis
7 Lungs                  17 Back Problem
8 Multiple Sclerosis     18 Diabetes
9 Amputee                19 Nerve, Muscle Disorder
10 Epilepsy              20 Stroke

Please enter your name and address.

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Are you Male, or  Female

What is your age? 

Are you a wheelchair user?   YES   NO 

Where did you first hear about our web site?  

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