Associate Registration

Welcome to the Cerebral Palsy Group. If you are a Professional with Cerebral Palsy who is interested in being part of The Cerebral Palsy Group's ongoing forums and debates, as well as upcoming conferences, OR if you would like to share your time and expertise with an aspiring entrepreneur. Please fill out this brief form to join our growing list of Associates. Associate fee is $25.00 per year.

I am joining as a/an (required): Associate Partner

First Name (required):
Middle Name:
Last Name (required):

Street Address (required):
City (required):
State (required):
Zip Code (required):

Telephone # (required):
Fax #:

Primary E-Mail (required):
E-Mail to display on on-line profile:

Occupation (required):

Is your speech affected? (required): Yes No

Do you use any of the following assistive devices? (check all that apply): Wheelchair Power Wheelchair Scooter Crutches/Canes Touch Talker Head Stick Service Animal Other, please specify

Are you interested in being a mentor? (required): Yes No

Are you interested in information about upcoming events? (required): Yes No

Please take a moment to list your credentials, your professional accomplishments and any other information you would like to share with other affiliates of the Cerebral Palsy Group (required).

I am interested in serving on the following committees (check all that apply): Blue - Grow the organization Red - Communication Yellow - Consulting/mentoring Green - Obtaining funding

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