Please contact me!

Parent/Caregiver Name:

Summit or Portage County Street Address:

City:    Zip:

Daytime Telephone:    Evening Telephone: 

Client Information:

Name:      Age:

Gender: Male    Female

Please share information regarding your loved one's needs, or questions about the Personal Advocacy program, and how it might fulfill a need in your family:

Thank you for taking the time to share this information with us. The Arc looks forward to the opportunity to further serve the needs of your family.

A staff member will contact you by telephone or email to answer your questions or arrange a preliminary meeting to discuss your needs.