Resource Validation Form – Arizona Spinal Cord

First Name

Last Name

Name of Business

Established

Telephone

Hours of Operation

Fax

Toll-Free

TTY

Address

City

State

Zip

Website

Physicians

Government Programs

Home Services

Therapy and Support Services

Professional Services

Durable Medical Equipment

Transportation Solutions

1. Are you familiar with the Arizona Spinal Cord Injury Association (AZSCIA)?

2. Do you have someone in the office that is bilingual? If so, please list languages spoken

3. Would you like to receive our free monthly newsletter?

4. Is your office wheelchair accessible and user friendly by persons with mobility impairments?

5. Do you have previous experience working with individuals with a SCI (spinal cord injury)?

6. Designated accessible parking?

7. Does your office have accessible restrooms?

8. Are there multiple locations? If so, please list below.

9. Would you like to provide any additional information about the services you provide?

Choose One
I certify that all information provided as part of this application is true and correct to the best of my knowledge. Any certifications and licenses required of my profession have been obtained and are currently up to date. I give my consent to the Arizona Spinal Cord Injury Association to use this information provided herein for the purpose of resource considerations on the website and internal database.