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MDTAP AT Service Request
Thank you for reaching out to the Maryland Assistive Technology Program!
* Indicates required question
Email
*
Your email
Name (First & Last)
*
Your answer
Phone Number
*
Your answer
Preferred Method of Contact
*
Phone
Email
Videophone
Other:
Required
Is spoken English your primary language of communication?
*
Yes
No
Other:
Do you require translation services?
*
Yes
No
If yes, what translation support can we help provide you with?
Your answer
Zip Code
*
Your answer
Are you a US Veteran or a family member of a US Veteran?
*
Yes
No
What service are you requesting?
*
Choose
Device demonstration
Borrow a device from AT library
General AT consultation
Training
Presentation or outreach event
Funding AT
Digital Accessibility
None of the above
How would you best describe yourself?
*
Choose
Individual with a disability
Family, guardian, authorized rep
Health, allied health rep
Education rep
Employment rep
Community living rep
Technology rep
Please tell us more about your request:
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Your answer
A copy of your responses will be emailed to the address you provided.
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