Date:

Martial Status: Married Single Divorced Widowed Separated

Name:

Address:

City: County:

State: Zip Code:

Phone: Home: Cell:

Work (if it is okay to receive calls there):

Email address:

Newsletter: How would you like to receive our newsletter? U.S. Mail Email YahooGroup

Would you like to join one of our Listservs? Local area Listserv Advocacy Listserv

ADD/ADHD Listserv Autism Listserv Bipolar Listserv Dad's Listserv ECI

Listserv Homeschooler Listserv Medical Home Listserv Preemie or NICU Listserv

Transition Listserv

Occupation:

Hobbies/Special Interests:

Relationship with child with disability: Parents Mother Father Grandparent

Sibling Guardian Other:

Languages you speak other than English: Spanish Sign Language Other

Family Ethnicity: Multiracial African-American Asian-American Caucasian

Hispanic Native American Other:

Why do you want to be a volunteer and support other parents:
Do you want to support another parent as a Supporting Parent Volunteer?: Yes No

Do you want train Medical Residents as a Family Faculty for our MEd Program? Yes No

Do you want to be trained to provide trainings for parents and professionals through our Family to Family Health Care Information and Education Center? Yes No

INFORMATION ON INDIVIDUAL WITH SPECIAL NEED:

Name:

Date of Birth: Age:

Gender: Female Male

Child Ethnicity: Multiracial African-American Asian-American Caucasian

Hispanic Native American Other:

Please list all diagnosis/symptoms/etc.:

For us to understand more about your child, please indicate the level of function in each of the following catergories. For example, under cognitive, you might list "typical", "mild mental retardation", or "unknown".

Cognitive:

Mobility:

Behavior:

Speech/Communication:

Vision:

Hearing:

Toileting skills:

Eating skills:

Special equipment:

Other comments:

School program and school district OR daytime activities:

Siblings:

Name: Date of Birth:

Any special needs:

Name: Date of Birth:

Any special needs:

Name: Date of Birth:

Any special needs:

Name: Date of Birth:

Any special needs:

Where did you hear about Texas Parent to Parent? ECI Program School Agency

Phone Book Another parent Parent Group TxP2P flier or newsletter Internet

Other:

Please tell us how you heard about TxP2P: Another Parent A Parent from South Texas Team - Parent's Name Parent from DFW Team - Parent's Name Agency or Program ECI or DSHS Internet Phone Book

Other: