Peer to Peer Survey

This Peer-to-Peer survey will be evaluated to determine if there is interest in establishing a partnership program with the Center for Independent Living (CILO). The program would be for youth ages 13-18 who wish to develop relationships and participate with others with like or similar disabilities.

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* 1. What is your age?

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* 2. I identify my gender as....

Male

Female

Trans

Prefer not to answer

Fill in the blank

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* 3. What County do you live in?

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* 4. What activities would you like to participate in?

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* 5. Do you have any special needs that we could assist with?

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* 6. What day of the week would be best to get together with others?

Monday

Tuesday

Wednesday

Thursday

Friday

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* 7. What time would work best for you?

Mornings

Afternoon

Evening

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* 8. Optional- Contact Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 1. What is your age?

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* 2. I identify my gender as....

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* 3. What County do you live in?

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* 4. What activities would you like to participate in?

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* 5. Do you have any special needs that we could assist with?

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* 6. What day of the week would be best to get together with others?

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* 7. What time would work best for you?

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* 8. Optional- Contact Information

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* 9. Optional - Please provide your Date of Birth