Contact Information
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Title
Company
Address*
Email*
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Demographic Information

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If you require accommodations for a disability to participate at the Expo (such as American Sign Language interpretation, Braille, electronic format, etc.), please indicate as many as apply below before October 4, 2019.
American Sign Language Interpreter
Real–Time Captioning/CART (applies to workshops only)
Braille
Large print
Electronic Format
Other
Please Specify:
*Are you a healthcare or disability professional?
Yes
No
*Did you hear about Abilities Expo through social media?
If yes, through which social media did you hear about Abilities Expo? (Check all that apply.)
Facebook
Twitter
Instagram
Youtube
Other social media
Please specify which social media other than the ones above:
How else did you find out about Abilities Expo? (Check all that apply.)
Postcard (Direct Mail) San Jose Mercury News
San Francisco Chronicle East Bay Times
San Mateo Daily Journal Weekly community newspaper
TV: KPIX CBS, Channel 5 Text Message
Radio Mobile device ads
Magazine www.abilitiesexpo.com
Other Website Non-profit/Government Organization
School Abilities Buzz E-newsletter
Email Flyer
Abilities Expo Ambassador Friends/Family/Acquaintance/Co-worker
Other
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*Are you a person with a disability?
*Why did you decide to visit Abilities Expo? (Check all that apply.)
Latest disability products and services
Informative workshops
Adaptive activities like sports, dance and more
Networking
Meeting Micah Fowler
Other
Please Specify:
If yes, is the disability: (check all that apply)
Mobility Upper Limb Mobility
Vision Hearing
Developmental Autism Spectrum
Disease/Illness Cognitive
Sensory Other
Please Specify:
If you are not a person with a disability, are you a...?(check all that apply):
Friend/Family Member
Caregiver
Healthcare/Disability Professional
Dealer/Distributor
Manufacturer
Other
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*Have you attended a past Abilities Expo?
Yes, I have attended.
No, I have not.
*What is your gender?
Male
Female
Other
Please Specify:
*What is your age?
*In the next 12 months or sooner, do you intend to purchase any of the following? (check all that apply)
Adaptive Vehicle
Manual Wheelchair
Power wheelchair
Lifts / Ramps
AAC devices
Service animal
Just browsing
Other
Please Specify:
Click here if you would prefer NOT to receive the Abilities Buzz, an e-newsletter that conveys valuable information about people with disabilities and Abilities Expo events.
No, I do not wish to receive the Buzz.

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