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The BIAOR Network is a grassroots advocacy network for Oregonians concerned about issues important to people with brain injury. Network members receive timely information, action alerts and training opportunities to enable them to collaborate with others to influence public policy for the benefit of persons with brain injury and their families. Please complete the form below. When you finish, click "SUBMIT" to send the form electronically or you print the form send it via regular mail to BIAOR NETWORK, 540 24th Pl. N.E., Salem, Oregon 97301-4517. If you want more information or have questions, please call 1-503-740-3155 or 1-800-544-5243. |
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| Evening Phone | INCLUDE AREA CODE | ||
| Day Phone | INCLUDE AREA CODE | ||
| Fax | INCLUDE AREA CODE | ||
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What is your relationship to someone with disabilities? |
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FAMILY MEMBER (Birth year of family
member with disability): INDIVIDUAL WITH DISABILITIES SERVICE PROVIDER PROFESSIONAL OTHER |
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Which issues are most important to you?(check all that apply) |
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EARLY
INTERVENTION/EARLY SPECIAL EDUCATION
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| What is your primary area of interest?: | BRAIN
INJURY OTHER PHYSICAL DISABILITIES LEARNING DISABILITIES SENSORY IMPAIRMENT MENTAL HEATH LEARNING DISABILITIES DEVELOPMENTAL DISABILITIES Other |
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| I would like to receive the following free publications (check all that apply): |
The Oregon Clarion (quarterly email
newspaper on disability issues) The Clarion Bulletin (policy and legislative updates) The People First Connection (written by and for individuals with disabilities) |
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| What is your ethnic/racial identity? (optional) |
Hispanic/Latino African American/Black Caucasian/White Asian American Indian/Native American Native Hawaiian/other Pacific Islander Alaskan Native Russian/other East European Multiracial/Multicultural Other |
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What are your State Legislative and Congressional
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STATE SENATOR DISTRICT # |
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CONGRESSPERSON DISTRICT # |
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| I am interested in being actively involved, including being part of a telephone tree, writing letters, and meeting with policy makers. | |||
| I do not want to be actively involved, but keep me informed on the issues. | |||
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You are authorized to share my contact information with the Oregon Cross Disability Coalition so that I am able to receive updates and information relevant to my interests that may be sent from other advocacy sources. I understand this information is to be kept confidential and will not be released to outside organizations for any reason. I may rescind this authorization permission at any time by notifying you at the addresses provided above. .
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| ©2003 | | | Project Coordinator, Sherry Stock | | | Webmaster | | | News & Events | | | Email Task Force | ||