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Membership Sign-Up
Welcome to AGAPE. We're glad you've decided to become part of our family. The preliminary demographic information collected here will help us know how best to support you in your home among us. This information will be kept confidential within the organization.
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* Indicates required question
First & Last Name
*
Your answer
Address
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Birthdate
MM
/
DD
/
YYYY
Emergency Contact Name
Your answer
Emergency Contact Relationship
Your answer
Emergency Contact Phone Number
Your answer
Sight Condition
No Sight-loss
Age-related Macular Degeneration
Cataracts
Diabetic Retinopathy
Glaucoma
Retinal Detachment
Retinitis Pigmentosa
Albinism
Usher Syndrome
Other:
Any specific concerns to express? (Personal matters, etc.)
Your answer
Reasons for Joining
*
Community: To connect, socialize, and network
Information: To stay up-to-date on available tech and treatments
Independence: To learn ways to cope, remain active, and stay hopeful
Leadership: To build skills for job-readiness
Public Policy & Advocacy: To promote disability inclusion
Public Relations (PR): To promote public interest
Other:
Required
Consent to Media Release of Likeness (Photos, videos, etc.)
Yes
No
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