Let's Connect Survey

Let's connect!

A questionnaire designed to build new connections and be a bridge to resources.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Which county do you live in?
How do you identify your disability status?
What is your age?
How do you identify your ethnicity?
How do you identify your gender?
If you prefer to self-describe:
Do you have internet access for personal use?

YesNo
Do you need any equipment for virtual meetings?

computer: tower and screen, laptop, or tabletspeakersmousekeyboardassistive softwaresmartphonemodemrouterethernet cableexternal camera for video conferencingadaptive equipmentOther
What kind of activities are you interested in?

online board or card gamesvirtual dances/concertsvirtual family-style dinnershobby groups: gardening, knitting, cooking, languages, etc.book clubs with virtual meetingsphone calls/gamesvirtual artist exhibits/museum visitsvirtual meetupspenpalsvirtual lunch and learnmovie and discussionOther
Is there anything else you want us to know?
Are you filling this out on behalf of someone? If so, please indicate the individual's preferred method of contact and your name below:

phoneemailOther
Name of preparer

First NameLast Name
Should be Empty:

Let's connect!