Raise the Bar Interest Form

Raise the Bar Interest Form
Raise the Bar (RTB) is a nonprofit that aims to serve individuals with intellectual and/or developmental disabilities and their families in Camden, NJ.

Filling out this form lets us know you are interested in being connected to Raise the Bar's services. It will also give us more information to determine if you are eligible for RTB's services.

This form will take a total of 5 minutes to complete.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What is your preferred method of contact? (check all that apply)*

EmailPhone CallTextOther
How did you learn about us?
Are you the parent/ primary caregiver to a child with an intellectual and/or developmental disability?*

YesNoNot Sure
What is your relationship to the child?*

MotherFatherLegal Caregiver (that is not biological parent)Other Family MemberOther
What is your child's disability?*

Autism Spectrum DisorderDown SyndromeIntellectual DisabilityGenetic DisorderDevelopmental DelaysSpeech DelaysHearing ImpairedOther
(Optional) Please provide any additional information about your child's disability that you think is important for us to know.
How old is your child? *
Do you live in Camden City, NJ?*

YesNo
What is your zip code?*
Is your child enrolled in Camden City Schools?*

YesNo
What are current challenges you and your family are facing now? (Describe below)
What are you hoping to gain by being connected to Raise the Bar?
Do you have any questions or comments?
Should be Empty: