Please complete this form to help us plan future programming. * indicates required field First Name:* Last Name:* Email:* City/town of residence:* Bonita Springs Cape Coral Fort Myers Golden Gate LaBelle Lehigh Acres Naples Marco Island Port Charlotte Punta Gorda Other If Other, where? Seasonal / Year Round Resident:* Seasonal Year-Round Resident Is transportation an issue that determines whether you can participate in any or all activities at the MS Center? Yes No Sometimes If an issue, are you registered with a paratransit agency? If so which one: Goodwheels Passport (Lee County) Collier Area paratransit 3) Which of the following types of Support Group would interest you? Check all that apply. Caregivers/Care Partners Life Transitions: Recent Increase in Challenges Newly Diagnosed (0-3 years) Young Adults (18-30) Family & Career Challenges Men's Issues Other Other Support Group Interest: What day of the week works for you to attend programs? Check all that apply. Monday Tuesday Wednesday Thursday Friday Saturday What time of day works for you? Check all that apply Weekday morning Weekday afternoon Weekday evening Saturday morning Do you have suggestions/ideas for speakers or topics at future Lunch N Learn meetings? CAPTCHA Code:* You will be taken to Step Two: submit donation amount.