Upstream Access Membership Enrollment

About You

Upstream Access will not share your personal information. Your answers are only used to help improve our programs. You can skip any questions you do not feel comfortable answering.

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* 1. Your First Name and Last Name or initial

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* 2. Pronouns (optional)

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* 3. Email address

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* 4. Mailing Address for welcome gift (optional)

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* 5. What is your zip code or city you live in.

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* 6. Phone number (optional)

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* 7. How did you hear about Upstream Access?

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* 8. Is there a way you’d like to contribute your time and skills to Upstream Access?

Yes

Maybe

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* 9. If so how? (sharing your story, advocacy, art, etc.)?

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* 10. What’s one topic you’d like us to cover in a future newsletter, training, or webinar?

Support and Readiness During Emergencies

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* 11. On a scale of 1–5, how prepared do you feel for an emergency?

1 - Haven't thought about it

2- Thought about it, but not yet acted

3- Started to get organized

4- Have taken actions to get ready

5-Reviewed actions and told others

1 - Haven't thought about it

2- Thought about it, but not yet acted

3- Started to get organized

4- Have taken actions to get ready

5-Reviewed actions and told others

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* 12. If an emergency happened tomorrow, would you have a support network (pod) to check on you or help you?

I have a strong support network

I have a small support network

Not really, but I would like to

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* 13. Would you like help building your emergency plan?

Yes

Not yet

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* 14. Do you have solar powered items or a back up battery to meet your basic needs if the power went out ?

Yes

Some, but not all that I need

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* 15. Are there other access needs you would like us to know about that help you receive information in an accessible way?

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* 16. Would you like to schedule a 15-minute conversation to get to know Upstream Access and we can answer any questions you may have.

Yes

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* 17. How would you like a team member to contact you to schedule?

Phone call

Text

No preference

Thank you supporting Upstream Access and joining our membership program.