All information is kept confidential, and is soley used to determine what literature to send and or what peer visitor is best suited to handle you reqeust.	Sorry I changed my mind take me home!
Are you currently an amputee?	Yes No
What level amputation do you have?	Below the knee Above the knee Bilateral Leg Above Elbow Below the Elbow Bilateral Arm
What age group are you in?	under 18 18-39 40-55 55 and over
What is your gender?	Male Female
Would you like more information about attending our support group meeting.	Yes No
Would you like to receive amputee peer visiting literature?	Yes No
Would you like to have someone contact you regarding a peer visit?	Yes No
Name:
Email Address:
Sorry I changed my mind take me home!

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