Spinal Cord Injury Association of Kentucky(SCIAK) Membership Questionnaire
The Board members of SCIAK want to be sure your needs are being served. In an effort to help us identify your interests, please take a moment to complete the membership survey. All questions are optional. Please fill in as much of the survey as you feel comfortable doing.
Name
Address
City
State
Zip/Postal Code
Phone
Email*
Contact Person
Are you a SCIAK member? Yes No
Date you joined SCIAK
Date of Birth
Marital Status Single Married Divorced
Racial/Ethnic American Indian & Alaskan Native Black or African American Hispanic or Latino White not Hispanic or Latino Some Other Race
Educational Level High School Some College College Graduate Other
Do you have a spinal related disability? Yes No
What type of spinal related disability do you have?
When did you acquire your spinal related disability?
Are you currently living independently in the community? Yes No
Do you have a primary caregiver to assist you with daily activities? Yes No
Do you have available transportation to appointments, meetings, etc.? Yes No
What time of the day is most convenient for participating in activities in the community?
Where did you complete your rehab?
Do you know of any support groups for spinal related disabilities in your community? Yes No
If yes, where are they held?
Please check the following topics you would like to receive more information about in relation to people with spinal related disabilities:
Advocacy Athletics Community Transportation Current Research Developments Current Legislative Issues in KY Educational Opportunities Health Promotion Home Modifications Recreation Sexual Functioning Support Groups Stress Management Technology Volunteering Other
