Name Title

Affiliation

Address (please choose one, then fill in below) Business Residence

City State Zip

Phone Business Fax

Residence

I am a: Person with a disability Family member of person with a disability Friend/advocate/colleague of someone with a disability Professional working with people who have disabilities Interested citizen Other

If you choose "Person with a disability," "professional working with people who have disabilities," or "other," please specify the nature of your disability, your profession, etc. here.

Accessibility Needs: Braille Large Print 15/16 Audiotape 1-7/8 Audiotape ASL Interpreter Tactile Interpreter Transportation Spanish

I would like to be involved in: technology users peer network service provider network funding initiatives presenters network project governance (boards & committees) advocacy activities volunteer work

If you choose "volunteer work," please specify the type of work here.

Non-Delaware Residents: If you wish to receive copies of The AT Messenger, the annual subscription fee is $20. Make checks payable to the University of Delaware (EIN 51-6000297) and mail it to the address shown below with this application form (pdf version of form).

Delaware Assistive Technology Initiative
University of DE/duPont Hospital for Children
PO Box 269
Wilmington, DE 19899