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Updated Parent/Family Information
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* Indicates required question
Email
*
Your email
Name (First and Last)
*
Your answer
Child(ren)'s Name
Your answer
Mailing Address (Please include city and zip code in your response)
*
Your answer
Primary Phone Number
*
Your answer
Number of age of children with disabilities in your household that we have served.
*
Choose
1
2
3
4
5
6+
Please provide your child's year of birth. If multiple children have a disability within your home, please list all years of birth and provide disability label for each. Please list name of child and then details.
*
Your answer
Disability of child(ren) we have served
*
Autism
Deaf-Blindness
Deafness
Hearing Impairment
Developmental Delay (under age 5)
Emotional Disturbance
Intellectual Disability
Multiple Disabilities
Orthopedic Impairment (physical)
Other Health Impairment
Specific Learning Disability
Speech or Language Impairment
Traumatic Brain Injury
Visual Impairment including Blindness
Child who is inappropriately identified
Child whose disability is suspected or not yet identified
Child whose disability was not disclosed
No Disability
Required
Please check the box(es) that represent your family, if any. This information is required by our federal grant and the data captured will not be linked to names.
*
Foster Care
Homeless
Juvenile Justice
Low Income
Migrant
Military
Native American
Rural
N/A
Required
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