Request Resources

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Request for Resources
Please fill out the following form to request medical, educational or employment resources for a child or adult with a disability.
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* Required
Email *
Your email
I have read and agree to Telic's Terms and Agreements *
Age of child/adult with disability
Clear selection
Type of disability
Your answer
Type of resource requested
Clear selection
Description of what you are looking for. Be specific.
Your answer
What county do you currently live?
Clear selection
Person requesting the resource is:
Clear selection
Contact information: Name and Phone Number
Your answer
Clear form
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