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Potential Member Information Form

Work Phone:  
Fax Phone:      
I am mostly interested in:
 Which option below best describes you?
Consumer/Individual with a disability
Family of individual with a disability
Rehabilitation Professional:
        Job Title
Educator:
          Teacher      Paraprofessional
          Therapist    Social Worker
          Child Study Team Member



Is there a specific device you are interested in?
How did you hear about Cerebral Palsy of New Jersey?
 I would like to receive the following Newsletters:

Are you interested in any of the other services offered by CP of NJ?
Augmentative Communication Evaluations     Computer Access Evaluations   
Home Accessibility Evaluations                       Educational Accommodations       
Work site Accommodations                             Assistive Technology Training    
AT Technical Assistance                                 Professional Development

Additional Comments or Questions