Survey

Please take a moment to complete the following survey. The goal of the survey is to gather the information we need in order to keep you up to date on the group’s activities. We really want to hear from you what we can do to best support you and your family.

Name:

Address:

City:

State:

Zip:

Phone Number:

Email:

Names and Birthdays of all children:

Can we include the above information in our family directory?

*If no, would you like to be included in our distribution list?

Do you prefer to receive information via email or regular mail?

How can our group better serve you? (i.e. more seminars, social events, fundraisers, etc.)

What are your particular needs in regards to Fragile X?

Rank in importance, 1 through 6, issues that our group can assist you with in your Fragile X journey. (1 most important, 6 least important)
Social networking (Group)
Social networking (one on one)
Educational/School Issues
Medical Interventions
Adult Issues
Fundraising

What topics are you most interested in for a seminar? (1 most important, 6 least important)
Educational Issues
Behavioral Issues
Genetics
Medication
Financial Planning
Long Term Care/Adult Issues

Any suggestions, concerns or other comments not covered: