What would you like to do?
Please choose one of the following options so that we will know how to process your support group information...
Register this Support Group for the first time
and receive one year of Free Support Group Membership , a value of $100. By registering as a first time support group member I will receive five copies of the inMotion magazine and First Step. This membership entitles the support group to have the name, city and state listed in our First Step publication and also be listed on the ACA website with name, City, State, phone number and e-mail. The membership includes a discount on educational materials and reduced registration to education meetings for support group members.
This Support Group is already registered
, please update my listing with the information I provide below.
Information submitted by: (*required fields)
*Name:
*Telephone:
*E-mail:
Support Group Contact Information: (*required fields)
*Support Group Name:
*Street Address:
Apt., Suite, etc.:
*City:
*State:
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Alabama
Alaska
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District Of Columbia
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Hawaii
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Maine
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New Hampshire
New Jersey
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New York
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*Zip:
*Country:
*Telephone:
Fax:
Web site:
E-mail address:
*Primary contact Name:
*Phone:
Fax:
E-mail address:
Alternate contact Name:
Phone:
Fax:
E-mail:
About Your Support Group:
What is your support group affiliation?
--Select One--
Agency
Facility
Independent
If your support group is affiliated with an agency or facility, please provide the name:
What year was your support group founded?
Approximately how many members do you have?
What is the best time to contact the support group?
--Select One--
Afternoon
Any time
Business hours
Daytime
Evening
Morning
Does your support group hold meetings?
Yes
No
If so, where are they held?
What is the meeting time?
When does the group meet (example - "third Wednesday of each month")?
What is the age target of your support group?
--Select One--
Senior
Adult
All ages
Children
Teenagers
What is your usual meeting format?
--Select One--
Discussion
Speaker
Planned Program
Social
All of the above
Do you publish a newsletter?
Yes
No
If so, what is the name of the newsletter?
Please indicate how often your newsletter is published:
--Select One--
Annually
Bi-monthly
Bi-weekly
Monthly
Quarterly
Semi-annually
Semi-monthly
Weekly
Do you reprint in Motion articles in your newsletter?
Yes
No
Does your support group conduct peer visitor training?
Yes
No
Do you have trained peer visitors?
Yes
No
Does your support group sponsor or participate in sports?
Yes
No
If so, what sports? (you can hold down the "control" key while selecting items with your mouse to make more than one selection):
--Select all that apply--
Baseball
Basketball
Bowling
Boating
Camping
Football
Fishing
Flying
Golf
Horse back riding
Horseshoes
Hunting
Inline skating
Pool
Parasailing
Rollerblading
Running
Snowboarding
Softball
Skiing
Sailing
Soccer
Snow Skiing
Surfing
Swimming
Tennis
Volleyball
Water skiing
White water rafting
What other activities does your support group sponsor? (for example, annual picnic)
Does your group wish to be contacted for professional and academic surveys?Yes
No
