Individuals/groups interested in engaging with ASPECT can complete this application. Please email Julie Grutzmacher, Director of National Collaboration and Engagement at Prevent Blindness with questions at: [email protected] Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Suffix Email* Preferred mailing address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone number*Please indicate whether the telephone number is mobile or landline*MobileLandlineEthnicity/Race* American Indian or Alaskan Native Asian Black or African American Hispanic, Latino, or Spanish origin Native Hawaiian or other Pacific Islander White Multi-racial/Other (Please check all that apply)Please indicate your prospective role in the program.* Patient Ally/Caregiver Representative from nonprofit or industry partner Clinician/Researcher (Please check all that apply)If you are a patient, what is your vision diagnosis?*If you are an ally/caregiver, what is your loved one's vision diagnosis?*Tell Us More About Yourself and Your ExperienceWhy do you want to be involved in the A.S.P.E.C.T. program?*What 1-2 things would you like to see improved or changed in the lives of people with vision impairment or blindness?*If you have experience or specific training in the advocacy process, please describe. (This can be anything from self-advocacy to advancing public policy).Is there anything else you would like us to know?
