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* 1. Please provide your contact information:

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* 2. United Spinal chapter affiliation:

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* 3. Please select: (optional)

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* 4. Please select your level of injury (or the level of the person you are representing):

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* 5. Mobility equipment usage: (check all that apply)

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* 6. Please check the following items you use:

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* 7. Please list any assistive technology device that you utilize:

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* 8. As our Tech Access Initiative seeks to get individuals mobility disabilities involved as testers and authorities on their needs as customers, we are looking for diverse individuals with personal and technology industry insights.

Please tell us a bit more about yourself and your relationship with technology, including any specific training or professional technology related experience or perspective:

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* 9. Beyond personal computing and their related assisted technology devices, please list any other tech areas you are interested in or specific products you utilize (i.e. medical device technologies, mobility tech devices, web accessibility, artificial intelligence, autonomous vehicles, videogame accessibility, tech related policy etc.):

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* 10. In the future, United Spinal's Tech Access program will offer opportunities for members in the following areas, please check boxes for activities where you would like to participate (compensation for time and expense will vary):

Thank you for your time, and we look forward to working with you as we roll out this important initiative.
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