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* 1. Address:

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* 2. Are you a

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* 3. What services do you or your family member receive? Check all that apply. 

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* 4. If you are waiting for services, what waitlists are you on? Check all that apply. 

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* 5. If you are on a waitlist(s), what is your statewide waitlist number? Please indicate which waiver(s) you are waiting for.

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* 6. How many years have you been on a waitlist for services?

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* 7. Are you or your family member 22 years of age or older? 

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* 8. Do you or your child receive special education services? 

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* 9. What is your current work situation? Check all that apply. 

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* 10. Are you interested in helping The Arc of Texas advocate to reduce the waitlist for Medicaid waiver services? 

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