Survey - California Privacy Law - Postal Mail Opt-Out

1.

Please complete the information below:

*

Name:

Title	First Required	Middle Required	Last Required

Email

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number:

Yes, I would like to receive email from Easterseals

2.

Question - Not Required - You must check the box below to remove this address from Easter Seals' postal mailing list.

Yes, I would like to be removed from Easter Seals' mailing list. I understand this may take 8-12 weeks.

3.

Question - Not Required - Additional questions or comments:

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