Inland Empire Disability Resources Expo Registration Form
First Name *
Last Name *
Address *
Zip *
City *
State *
Phone Number *
Email Address *
* Required
Age
Name
Please list any persons under 18 years of age that you will be bringing to the Expo.
1.
2.
3.
4.
5.
Are you a... (check all that apply)
Person with Disability
Caregiver
Family Member
Service Provider
Older Adult/Senior
Friend
Other
How did you hear aboutthe Expo? (Check all that apply)
Newspaper
Radio
Magazine
Website
Email
Billboard
Poster
Work
Other
Friend
Do you need a disability-related accommodation? If no, leave blank.
Would you like to receive information about future IEDC events via email/mail?
Yes
No