Cogentica Registration Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Though subject to change, the primary purpose of the disability registry is to have a listing of disabled individuals who we can contact to participate in survey and marketing studies that are useful to the disability community. All solicited information is voluntary and you can skip any fields you are uncomfortable completing. Needless to say, all your responses are completely confidential and will not be released with any identifying information. At a minimum, please provide your email, zip code, age, gender, and disability category. Name *FirstLastEmail *AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeGenderMaleFemaleOtherAge Category18-2021-2526-3536-5051-6566 or olderDisability CategoryHearing Difficulty - deaf or having serious difficulty hearingVision Difficulty - blind or having serious difficulty seeing, even when wearing glassesCognitive Difficulty - Because of a physical, mental, or emotional problem, having difficulty remembering, concentrating, or making decisionsAmbulatory Difficulty - Having serious difficulty walking or climbing stairsSelf-Care Difficulty - Having difficulty bathing or dressingIndependent Living Difficulty - Because of a physical, mental, or emotional problem, having difficulty doing errands alone such as visiting a doctor’s office or shoppingThe disability categories are useful should we seek to select individuals for participation in surveys or marketing studies. Please select all categories that are relevant. Custom Captcha * = Submit
