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Adapt to Your New Potential
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Name
*
First
Last
Email
*
Age
*
Gender Identity
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Male
Female
Nonbinary
Other
Who Has a Disability
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Me
My Spouse/Significant Other
My Child/Grandchild
My Sibling
My Friend
A Member of a Group/Team I lead
A Colleague
Other
Please Elaborate on the Previous Question
Please include the gender identity, age, and extent of relationship to the person with a disability.
What Best Describes the Disability? (Select All that Apply)
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Paralysis
Amputation
Vision Impairment
Hearing Loss
Nonverbal
Autistic
Chronic Illness
Please Describe the Disability (Be Specific As Possible)
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How Long Have You or the Person You Know Been Disabled?
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Please Describe Any Special Accommodations Needed for the Disability in Question
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Does this Disability Require Continence Care Products? If So, Please Elaborate
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Is There Any Other Information You Would Like to Share?
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