Family Services Community Connections eNews! Survey

Question Title

1. Do you receive the monthly Community Connections eNewsletter?

Yes, I receive the monthly Community Connections eNewsletter!

No, and I am not interested at this time.

I want to sign up today! Please provide your name and email address in the box below.

Question Title

2. What is your connection to autism?

I am an individual with autism

I am a parent of an individual with autism

My family has a member with autism

I work with individuals with autism

I know someone with autism

Other (please specify)

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3. Choose the autism topics you are interested in by age range (check all that apply)?

	0-2 years	3-5 years	6-13 years	14-21 years	22 years and older
Advocacy	Advocacy 0-2 years	Advocacy 3-5 years	Advocacy 6-13 years	Advocacy 14-21 years	Advocacy 22 years and older
Community Activities	Community Activities 0-2 years	Community Activities 3-5 years	Community Activities 6-13 years	Community Activities 14-21 years	Community Activities 22 years and older
Financial Support	Financial Support 0-2 years	Financial Support 3-5 years	Financial Support 6-13 years	Financial Support 14-21 years	Financial Support 22 years and older
Health Care	Health Care 0-2 years	Health Care 3-5 years	Health Care 6-13 years	Health Care 14-21 years	Health Care 22 years and older
Legal Issues	Legal Issues 0-2 years	Legal Issues 3-5 years	Legal Issues 6-13 years	Legal Issues 14-21 years	Legal Issues 22 years and older
Programs and Services	Programs and Services 0-2 years	Programs and Services 3-5 years	Programs and Services 6-13 years	Programs and Services 14-21 years	Programs and Services 22 years and older
Respite Care	Respite Care 0-2 years	Respite Care 3-5 years	Respite Care 6-13 years	Respite Care 14-21 years	Respite Care 22 years and older
Safety Issues	Safety Issues 0-2 years	Safety Issues 3-5 years	Safety Issues 6-13 years	Safety Issues 14-21 years	Safety Issues 22 years and older
Technology	Technology 0-2 years	Technology 3-5 years	Technology 6-13 years	Technology 14-21 years	Technology 22 years and older
Transportation	Transportation 0-2 years	Transportation 3-5 years	Transportation 6-13 years	Transportation 14-21 years	Transportation 22 years and older

Additional Suggestions (please specify)

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4. Do you have suggestions about how we could improve Community Connections eNewsletter?

Webinars on autism topics

Video examples

Other (please specify)

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5. I would like to update my email address to receive Community Connections eNewsletter!

Name:

Email Address:

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6. Based on your experience with Community Connections eNewsletter!, how likely is it that you will become a supporter of Autism Speaks?

Certain

Very likely

Unlikely

Very unlikely

I am a supporter of Autism Speaks

Comments (please specify)