Step
One - Get on our Mailing List |
Name |
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EMail |
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Check
all that apply:
Please send me updates regarding the Molly Hale DVD Project
Please let me know how I can participate in focus groups or outreach
efforts
Please let me know how I can make a tax-deductible contribution
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If you prefer not to take our brief survey, click "submit" to get on our mailing list.
Or, take the survey and click on "submit" at the bottom of this page.
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Step
Two - Take Our Short DVD Survey
Everyone who completes the survey is automatically
entered in a drawing to win one of five Molly Hale DVDs (expected
late 2004). All personal information is kept confidential, and
is used solely for the purpose of helping us generate content
that serves the differently-abled community.
|
demographics |
home
state |
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home
zip code |
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gender |
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age |
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community |
how
did you learn about MollyHale.com? |
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help
us understand our audience so that we can serve you better.
please
check all that apply
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I am recovering from a spinal cord injury |
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I can stand, but need a cane, walker, or other mobility aid to get
around |
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I need a wheelchair or scooter to get around |
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I have limited use of my hands or arms |
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I have limited grip strength due to arthritis |
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I have limited grip strength due to injury |
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I am paraplegic |
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I am quadriplegic |
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I am a caregiver for someone with mobility or grip issues |
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I am a family member of someone with mobility or grip issues |
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I am a physical therapist or professional bodyworker |
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I am a physician, nurse, or chiropractor |
interests |
I
would like to know more about:
(please
check all that apply)
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Adaptive Home Design |
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Bodywork - Massage, Chiropractic, Rolfing |
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Therapeutic Horseback Riding |
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Therapeutic (heated) Pools |
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Support Groups for the differently-abled |
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Medical Research on Spinal Cord Injury and Repair |
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Rehabilitation and Physical Therapy |
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Adaptive Tools for grip-challenged adults |
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Coping with the emotional stress of traumatic injury |
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How to prevent "Caretaker Burnout" |
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How to create and sustain a support network |
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Wheelchair Travel |
Other |
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To submit your responses, and be entered into a drawing for a free
Molly Hale DVD, please hit "submit" at right.
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Welcome
to the MollyHale.com Community!
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