Advisory Council

If you are interested in joining our Advisory Council, please fill out the form below. Thank you!

Date(Required)

Name(Required)

First Last

Address(Required)

Street Address City State ZIP / Postal Code

Email(Required)

Enter Email Confirm Email

Phone(Required)

I experience a disability (please specifiy)

I am a family member or guardian of an individual experiencing a disability (please specifiy)

I am an agency representative for:

Other (please specify)

Please share a brief description of your background and experience in obtaining, using, and/or providing assistive technology devices.

Please describe the type of activities or organizations you have been involved with regarding disability related issues.

Why would you like to be a member of the ATP Advisory Council?

Have additional information you would like to share?

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