Local Newtork Participation Survey 1. Local Network Participation Survey Question Title * 1. Please provide your first and last name and e-mail address: (all information is kept strictly confidential) (Required.) Name: Email Address: Question Title * 2. Please provide your address and phone number Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Phone Number: Question Title * 3. Please indicate which of the following you are interested in (select all that apply) I would like to be on the local SADS Network Group mailing/email list and share or be notified about local resources, local events, get-togethers, etc. I would like to be in a directory available to local individuals and families (you can choose what information to list). I would be interested in networking via email or phone with families who have similar issues. I would be interested in meeting as a group. Question Title * 4. If you would like to meet as a group, how often would you like to meet? Monthly Quarterly Every other month 1 or 2 times a year Other (please specify) Question Title * 5. Would you be willing to host a meeting at your home, or secure a meeting place in your area? Yes No If yes, please state when Question Title * 6. What Network Group activities would be meaningful for you? Social Gatherings Fundraising to support SADS programs Children’s Play Group Teen Support Media A page on the SADS Website specifically for our group Ideas for individual awareness activities in the community SADS Group Projects Coordinated awareness project Advocacy Medical Education Informational Seminar (e.g. invite a local physician, etc.) Other (please specify) Question Title * 7. If you would be interested in taking a leadership role for any of the group activities listed above, please specify. Question Title * 8. If you would like to be in a local directory, to be given to other individuals and families, please indicate what contact and background information you would like in the directory: First Name. Last Name. Last Initial. Address. City. Zip. Email. Phone. Whether you have lost a loved one to a SADS condition. Whether anyone in your family has an ICD. Age & gender of diagnosed children, and whether they have an ICD. Which SADS condition is in your family (please indicate) Question Title * 9. If you would like to provide information about whether your family has experienced a loss, has an individual with an ICD, or any children or teens who could benefit from support please describe below: (consider listing child’s ages, gender, what type of sports or activity they participate in etc.) Question Title * 10. If you would like, please tell us about your educational background, profession, interests and skills. Next