Consumer Information Form

Ocean State Center for Independent Living

Phone

401-738-1013

info@oscil.org

First Name

Last Name

Birthday

Phone

Please enter your primary disability or disabilities

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

I feel that I have achieved my goal to participate in a peer support/socialization activity that will also increase my knowledge of available servces and resources.

I wish to waive establishing a comprehensive Independent Living Plan (ILP) at this time.

I wish to speak with an Information & Referral Specialist about OSCIL services.

I have worked or am currently working with OSCIL.

Other

Comments

I would like to receive OSCIL's quarterly newsletter

I want to subscribe to the monthly e-newsletter.

Your Signature