CPABC Gamers Club Giveaway Application
Personal information
First name: Last name: Date of birth: Phone: Email: Address: Are you a CPABC member:
Medical information
Do you have a formal diagnosis of cerebral palsy:
Description of your CP and its effect on your mobility:
Do you require an adaptive controller for gaming:
Impact of receiving a PS5
1) How would receiving a PS5 impact your ability to connect with others socially?
2) Do you currently experience feelings of social isolation:
3) How do you think gaming could improve your mental health and overall well-being?
4) Do you currently play video games? If so, what types of games do you enjoy?
5) Do you have access to a stable internet connection for online gaming and virtual meetups:
Commitment to CPABC Gamers Club Monthly Discussion Group
Are you willing to commit to attending six monthly virtual discussion:
Consent & Agreement
By signing below, I confirm that the information provided is accurate. I understand that if selected, I will receive a PlayStation 5 and adaptive controller and commit to attending six virtual discussions as part of the CPABC Gamers Club. I also consent to being contacted regarding this program.
Parent / Guardian Name:
Leave this empty:
Your legal name
Your email address
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Document Name: CPABC Gamers Club Giveaway Application
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