TheCPGroup.org Associate Registration

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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. There is a $25.00 per year associate fee. This fee helps us cover administrative costs.

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I am joining as a/an (required): Associate   Partner
First Name (required):
Middle Name:
Last Name (required):
Address (required):
City (required):
State/Province (required):	not available Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland and Labrador New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
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).
Personal Website (do not enter http://):
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