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For all TAG (Tech Access Group) members to complete 

This information that you provide will be used to best match you with the opportunities Tech Access has for Research and Development and User Experience.  

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* 1. Are you a member of United Spinal? Membership is free.

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* 2. What is your United Spinal chapter affiliation: (if applicable)

If you would like to join a chapter network click here.

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* 3. Please provide your contact information:

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* 4. In what year were you born? (enter 4-digit birth year; for example, 1976)

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* 5. What is your race or ethnicity?

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* 6. Are you of Spanish, Hispanic or Latino origin or descent?

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* 7. What is your gender?

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* 8. Please provide your social media (personal or professional). This will not be shared without your permission.

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* 9. Please provide other disability organization affiliations and your role (List any or all)

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* 11. Which of the following best describes your functional level?  

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* 12. For those with SCI, please indicate your neurological level:

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* 13. What is your level of injury?

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* 14. Would you like to disclose any other disabilities or identities that add to your perspective intersectionality? If so, please provide:

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* 15. Please provide the make and model of wheelchair(s) and mobility devices you own: (leave blank any that do not apply to you)

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* 16. What type of transportation do you use most frequently? (select only one)

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* 17. For your personal vehicle, are you the primary driver?

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* 18. Please elaborate specifics on your use of the following products (use N/A for items or services you do not own):

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* 19. Please select the assistive technology device(s) that you utilize:  (check all that apply)

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* 20. Please tell us a bit more about yourself and your relationship with technology, including any specific training or professional technology related experience or perspective. Prior training is not a requirement to sign up.

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* 21. Beyond personal computing and their related assisted technology devices, please list any other tech areas you are specifically interested in or have expertise with:

  Interest Expertise
Medical device tech 
Mobility tech devices 
Artificial Intelligence 
Autonomous vehicle 
Video game accessibility 
Smart home devices 
Tech related policies 

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* 22. United Spinal’s Tech Access program has opportunities for members in the following areas. Please select the activities in which you would like to participate. Please mark as many boxes as possible that apply to you (compensation for time and expense will vary):

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* 23. For those interested in public speaking opportunities, please upload a personal bio (150-200 words) highlighting your background and any tech or advocacy-related skills or previous experience (if available include any links to presentations or conferences that you have been a part of): 

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