CONTACT INFORMATION

Your Name
Name of Person seeking service:
Address:
City:
Zip Code:
County:
Home Phone Number:
Work Phone Number:
Your Story Please provide a brief description of your family member who is seeking services:
Please provide a short statement of the needs of the person seeking services:
Please describe the impact of the lack of services [or something like this] on the person seeking service and your family:
Upload a picture of the person seeking services!
I give my permission to use the story as stated above in materials distributed to Tennessee Legislators for the purpose of educating them on my family member needs and services. I give my permission to use my family member’s picture in materials distributed to Tennessee Legislators for the purpose of educating them on our needs for services. I give my permission to use both my story and family member’s picture on The Arc of Tennessee website for educating both legislators and the general public on the needs of people with intellectual disabilities (mental retardation)

Last Updated 04/1/08