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Family Empowerment Series for Parents of Children with Special Needs
Location: Howland Public Library 313 Main Street, Beacon, NY 12508
Date and Time: Oct. 17th, 20th, 24th, 27th, Nov. 7th, 10th, 14th and 17th from 10:00 AM - 2:00 PM
Please note by completing this form you are committing to attend all 8 sessions. If you are unable to attend all 8 sessions please contact Denise Green at 845.228.7457 x. 1102.

Please answer all questions, then click "submit" at the end of the form. This information is needed for our funding sources, which allows us to provide these free workshop sessions. Thank you!

First Name *
Your answer
Last Name *
Your answer
Day Time Phone Number *
Your answer
Email Address: *
Your answer
Please Enter your Full Address including City. (Professionals - work address; Parents - home address) *
Your answer
In What Capacity are you attending this event? *
If you are a professional/ service provider, please list the name of your organization (Parents type N/A) *
Your answer
If you are a professional/service provider please list your title (Parents type N/A): *
Your answer
Location of Work Professionals (Parents please check N/A) *
Location of Home for Parents (Professionals please check N/A) *
I live/work in an area that is (Parents - home, Professionals work) *
I describe my Ethnicity as: mark only One *
I describe my race as (check all that apply) *
If you are a parent of a child with a disability, please choose age range (professionals please check N/A) *
Parents please choose if your child has an: (professionals check n/a) *
Parents if you child has an IEP please choose the educational classification for your child (Please choose one only) *
Your answer
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