CHANCE will provide an alternative to the traditional agency controlled services that have a vested interest in maintaining congregate living and the institutionalization of people with disabilities. For this reason, your support is critical. Please give us permission to use your name as a collaborator in these efforts.

Please list our organization as a collaborator with CHANCE Yes No

Name of Organization:

Contact Person:

Address:

City: State: Zip:

Phone: Fax:

TDD: Email:

Our organization is: national state local

Please include me as an individual collaborator with CHANCE Yes No

Date: