Support Parent Information Submission

Full Name:
Daytime Phone
Evening Phone
Email Address:
Street Address
City, Zip
If your child is in school still, in what school district do you reside?
How would you describe your relationship with your child's school district?
Is your child a Regional Center client?	Yes No
I prefer to be contacted in the:	Morning Afternoon
What is the best daytime number to reach you?
Your Child's Current Age, for security do not enter date of birth
Your child's gender:	Female Male
What is your child's primary condition?
Please list any additional conditions that your child or children may have. (list all that you are willing to share):
List treatments, procedures, or surgeries that your child has had that you would be willing to talk about with another parent.
Does your child use any adaptive equipment or assistive technology? If so, which.
Is your child taking medications?
Please list the area's that you have knowledge in related to special needs. For example: G-tubes, IHSS, Special Diets, etc.:
Check the trainings that you have attended:	Individualized Education Planning (IEP) Individualized Family Service Plan (IFSP) Mentor Parent
Would you be willing to attend an IEP with another parent?	Yes No
Other training you have attended:
Other than English, what other languages do you speak?	Cambodian Catonese Hindi Hmong Japanese Korean Laotian Mandarin Tagalog Spanish Vietnamese
Languages not included in the list above:
Cultural /ethnic background:
How did you first learn of PHP?