Parent Name(Required) First Last Phone(Required)Email(Required) Enter Email Confirm Email Applicants Name(Required) County Of Residence: HiddenInvoice Number: Please use the first two letters of first and last name followed by the date of birthDOB Date of BirthPrimary Language Gender Male Female Self Identify Decline To state Self Identify Race Ethnicity African American / Black Pacific Asian Caucasian / White East Indian Hispanic Native American Pacific Islander Decline To State Other Race Ethnicity (Other) What is the nature of your disability: Amyotrophic Lateral Sclerosis (ALS) Aphasia Apraxia Autism Cerebral Palsy Development Disability Dysarthria Huntington’s Disease Larynx Disorder Muscle Weakness Oral Cancer Stroke Stuttering-Stammering Traumatic Brain Injury Vocal Cord Damage Other: What is the nature of your disability (Other) How did the applicant first hear about the Voice Options Program? ILC AT Center Medical Provider Social Media Other: How Did The Applicant Hear From Us (Other) For which of the Following purposes did you use your iPad and speech application, check all that apply: Call in a prescription refill Attend video appointment Call to schedule an appointment Call contact friends/family Call your bank Call to make a purchase Other: Using iPad For Speech Application (Other) CAPTCHA Δ
