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Workshop Registration Form with Lone Star Abilities Network at Scottish Rite Hospital Frisco
Attendee Registration Form (Formulario de registro de asistentes)
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* Indicates required question
Email
*
Your email
Attendee Name (Nombre)
*
Your answer
Full Address City Zip (Dirección de envio )
*
Your answer
Phone Number (Número de teléfono)
*
Your answer
Which best describes you?
*
Choose
Parent of a child with a disability (Padre de un niño con discapacidad)
Grandparent of a child with a disability (Abuelo de un niño con discapacidad)
Family member of a child with a disability (Miembro de la familia de un niño con discapacidad)
Legal Guardian of a child with a disability (Tutor legal de un niño (s) con discapacidad)
Professional (Profesional)
I am a parent of a child with a disability and a professional in the disability field (Soy padre de un niño con discapacidad y profesional en el campo de la discapacidad)
Self-advocate (Abogado (de 18 a 26 años))
Youth (ages 14-26) Juventud (de 14 a 26 años)
What is your ethnicity? (Cuál es tu etnia?)
*
Choose
Latino or Hispanic (Latino o hispano)
Not Latino or Hispanic (No latino o hispano)
I do not wish to disclose (No revelado)
What is your race?
*
Choose
Hispanic or Latino - N/A (Latino o hispano- N/A)
Caucasian/White
African American/Black
American Indian/Native American/Alaskan Native
Asian/Indian
Native Hawaiian/Pacific Islander
I do not wish to disclose (No revelado)
What is your child's disability or complex medical need?
*
Choose
I am a professional - N/A (Soy un profesional - N / A)
Autism (Autismo)
Deaf-blindness (Sordoceguera)
Deafness (Sordera)
Hearing impairment (La discapacidad auditiva)
Developmental Delay - Early Childhood (Retraso del desarrollo: primera infancia)
Emotional Disturbance (Disturbio emocional)
Intellectual Disability (Discapacidad intelectual)
Multiple Disabilities (Discapacidades múltiples)
Orthopedic Impairment (physical) (Discapacidad ortopédica (física))
Other health impairment (Otro deterioro de la salud)
Specific Learning Disability (Discapacidad Especifica de Aprendizaje)
Speech or language impairment (Discapacidad del habla o del lenguaje)
Traumatic Brain Injury (Lesión cerebral traumática)
Visual Impairment - including blindness (Discapacidad visual, incluida la ceguera)
Child who may be inappropriately identified (Niño (s) que pueden ser identificados de manera inapropiada)
Disability is suspected but not yet identified (Se sospecha discapacidad pero aún no se ha identificado)
I do not wish to disclose (No deseo revelar)
No Disability (Sin discapacidad)
N/A
What is your child's name? (¿Cuál es el nombre de su hijo?)
*
If you are a professional, please put N/A (Si es un profesional, ponga N / A)
Your answer
What is your child's ethnicity? (¿Cuál es la etnia de su hijo?)
*
Choose
I am a professional - N/A (Soy un profesional - N / A)
Hispanic/Latino (Latino o hispano)
Not Hispanic/Latino (No latino o hispano)
I do not with to disclose (No deseo revelar)
What is your child's race? (¿Cuál es la raza de su hijo?)
*
Choose
I am a professional - N/A (Soy un profesional - N / A)
Hispanic or Latino - N/A (Latino o hispano - N/A)
Caucasian/White
African American/Black
American Indian/Native American/Alaskan Native
Asian/Indian
Native Hawaiian/Pacific Islander
I do not wish to disclose (No deseo revelar)
Child's YEAR of Birth (Fecha de nacimiento de su hijo) If Professional, mark N/A
*
Your answer
Professional - What is your job title and company name? (Profesional - ¿Cuál es su puesto de trabajo y el nombre de su empresa?)
Your answer
What is your primary spoken language? (¿Cuál es su idioma principal hablado?)
*
English (Inglés)
Spanish (Español)
Other (Otro)
Please choose all that apply to you and your family. (For grant purposes only. This information will not be shared) Elija todas las que se apliquen a usted y su familia. (Solo para fines de subvención. Esta información no se compartirá)
*
Foster Care (Orfanato)
Homeless (Sin hogar)
Juvenile Justice (Justicia juvenil)
Low Income (De bajos ingresos)
Migrant (Inmigrante)
Military (Militar)
Native American (Nativo americano)
Rural
N/A
Required
I would like to receive the PACT monthly newsletter. (Me gustaría recibir el boletín mensual de PACT.)
*
Yes (Sí)
No
Required
I am attending the following session date(s) at 6:30 PM-8 PM
*
Aug 12 Parents- What's the Big IDEA Behind Inclusion
Aug 12 YOUTH 14plus -Youth Skills for every job?
Oct 14 Parents- Documentation and Orgainzing Paperwork
Oct 14 YOUTH 14plus What is Transition?
Dec 9 Parents- Creative Parenting
Dec 9 YOUTH 14Plus Teambuilding/Celebrate Holidays
Required
I am interested in learning more about Parent Leadership Training. (Estoy interesado en aprender más sobre la Capacitación de Liderazgo para Padres.)
*
Yes (Sí)
No
Required
I am interested in learning more about Youth Leadership Training. (Estoy interesado en aprender más sobre la Capacitación de Liderazgo Juvenil.)
*
Yes (Sí)
No
How did you hear about Partners Resource Network? (¿Cómo se enteró de Partners Resource Network?)
*
Your answer
Send me a copy of my responses.
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