Survey - Regional Advocacy Survey

Regional Advocacy Survey

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Question - Required - Are you interested in joining a regional advocacy group of family members and supporters dedicated to bringing attention to the issues impacting our community?

Please fill out the form below, so we can best match your interests:


*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Street 1: Required
*	City: Required
*	State / Province: Required
	ZIP / Postal Code:
	Phone Number:
	If you respond and have not already registered, you will receive periodic updates and communications from AHRC Nassau.

Question - Not Required - Would you like to opt-in to receive advocacy text messages? If so, please enter your cell phone number. If not, leave blank.

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Question - Required - Please select all that apply:

	I'm a staff member at AHRC Nassau, Brookville Center for Children's Services, and/or Citizens Options Unlimited
	I receive services from AHRC Nassau, Brookville Center for Children's Services, and/or Citizens Options Unlimited
	I'm an AHRC Nassau member
	My relative receives services from AHRC Nassau, Brookville Center for Children's Services, and/or Citizens Options Unlimited
	I'm a friend or supporter of AHRC Nassau, Brookville Center for Children's Services, and/or Citizens Options Unlimited
	I volunteer at AHRC Nassau, Brookville Center for Children's Services, and/or Citizens Options Unlimited
	I work in the field (not at AHRC Nassau, Brookville Center for Children's Services, and/or Citizens Options Unlimited)