Contact Information
Name*
Title
Company
Address*
Email*
Phone Number

Demographic Information

*Did you hear about Abilities Expo through social media?
Yes
No
Click here if you would prefer NOT to receive the Abilities Buzz, an e-newsletter that conveys valuable information about people with disabilities and Abilities Expo events.
No, I do not wish to receive the Buzz.
If you would like to receive Expo-related messages on site via text, provide your cell phone number.
Please Specify:
If you require accommodations for a disability to participate at the Expo (such as American Sign Language interpretation, Braille, electronic format, etc.), please indicate as many as apply below before May 31, 2019.
American Sign Language Interpreter
Real–Time Captioning/CART (applies to workshops only)
Braille
Large print
Electronic Format
Other
Please Specify:
*Are you a healthcare or disability professional?
Yes
No
If yes, through which social media did you hear about Abilities Expo? (Check all that apply.)
Facebook
Twitter
Instagram
Youtube
Other social media
Postcard (Direct Mail)
Billboard (Outdoor)
Chicago Tribune
Daily Herald
TV: WGN 9 Chicago
TV: NBC 5 Chicago
Mobile device ads
Magazine
www.abilitiesexpo.com
Other Website
Non-profit Organization
Abilities Buzz E-newsletter
Email
Flyer
Abilities Expo Ambassador
Friends/Family/Acquaintance/Co-worker
Other
Please Specify:
*Are you a person with a disability?
If yes, is the disability: (check all that apply)
Mobility Vision
Hearing Developmental
Autism Disease/Illness
Other
Please Specify:
If you are not a person with a disability, are you a...?(check all that apply):
Friend/Family Member
Caregiver
Healthcare/Disability Professional
Dealer/Distributor
Manufacturer
Other
Please Specify:
*Why did you decide to visit Abilities Expo? (Check all that apply.)
Latest disability products and services
]Informative workshops
Adaptive activities like sports, dance and more
Networking
Other
Please Specify:
*Have you attended a past Abilities Expo?
Yes, I have attended.
No, I have not.
*What is your gender?
Male
Female
Other
Please Specify:
*What is your age?
*In the next 12 months or sooner, do you intend to purchase any of the following? (check all that apply)
Adaptive Vehicle
Manual Wheelchair
Power wheelchair
Lifts / Ramps
AAC devices
Service animal
Just browsing
Other
Please Specify:

There are errors in your form, see details above!

Powered by TPNI - The Pulse Network - www.tpni.com