Support Group Registration

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Age (Optional)

Race/Ethnicity (Optional)

Other

Gender Identification (optional)

Answer "none" if not applicable

Sexual Orientation (optional)

Marital Status (optional)

How many children do you have? *

How many of your children have disabilities? *

Please give a brief description of you child's disability. *

What would you most like to gain from attending this support group? *

Would it be helpful for you to attend if childcare was provided during the sessions?

How many children would you need childcare for?

Optional Donation

This parent support group is free to all participants, but donations are welcome with all proceeds going back into the group.

Other

Confidentiality *

I acknowledge that demographic information such as race/ethnicity, age, gender, and marital status, is collected and used only for reporting purposes. All identifying information including name, address, email, and phone number, as well as any information shared during sessions, will be kept confidential. Information will only be shared if I give my written consent.

Signature

Parent Support Group REgistration