Uncategorized Release of Information Parent Educational Support & Advocacy Intake Step 1 of 6 16% Name* First Last Your Child's Name* First Last Your Child's Date of Birth* MM slash DD slash YYYY Additional Child Check this box to add a child Additional Child's Name* First Last Additional Child's Date of Birth* MM slash DD slash YYYY Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Cell PhoneEmail* Preferred Method of ContactEmailHome PhoneCell PhoneName of other Parent/Guradian First Last Phone number of other Parent/GuardianHow did you learn about our programs? How can we support you?What is your major concern right now?How can our team best support you?What is your child's grade level and what school does your child attend? Additional Child: What is your major concern right now?Additional Child: How can our team best support you?Additional Child: What is your child's grade level and what school does your child attend? Tell us about your child.What are your child's hobbies, special interests, and skills? Does your child receive support from a local agency? If so, please tell us more about what support your child receives. Does your child receive free or reduced price meals? (Please note that this information is helpful for SNSC when applying for grant support; it will not be used in any other way) Does your child have a known diagnosis or a learning disability? Please tell us more. Which of these does your child identify as? (Check all that apply) Indigenous Asian Black or African American Native Hawaiian or Other Pacific Islander Hispanic Middle Eastern White Other Does your child receive any services now?(ex., OT, PT, SLP, etc.) Additional Child: What are your child's hobbies, special interests, and skills? Additional Child: Does your child receive support from a local agency? If so, please tell us more about what support your child receives. Additional Child: Does your child receive free or reduced price meals? (Please note that this information is helpful for SNSC when applying for grant support; it will not be used in any other way) Additional Child: Does your child have a known diagnosis or a learning disability? Please tell us more. Additional Child: Which of these does your child identify as? (Check all that apply) Indigenous Asian Black or African American Native Hawaiian or Other Pacific Islander Hispanic Middle Eastern White Other Additional Child: Does your child receive any services now?(ex., OT, PT, SLP, etc.) Please send most recent IEP/evaluation/behavior plan to Richard@snsc-uv.org* I understand that to receive advocacy services I need to send the most recent IEP/evaluation/behavior plan to Richard@snsc-uv.org Do you require any accommodations for your meeting with SNSC? Declaration & PermissionsYes,* I hereby give my permission for Special Needs Support Center to collect and store my personal information. Yes,* I confirm that you want to enroll in the Parent Educational Advocacy Program at the Special Needs Support Center. Additionally, you acknowledge that educational advocacy is a consulting position only and represents no legal or governmental authority. Yes,* I understand that my personal information may be shared with team members at Special Needs Support Center if necessary. March 3, 2021/by Kendra LaRoche https://snsc-uv.org/wp-content/uploads/high-res-logo-300x200.png 0 0 Kendra LaRoche https://snsc-uv.org/wp-content/uploads/high-res-logo-300x200.png Kendra LaRoche2021-03-03 00:33:512021-08-13 00:35:44Release of Information
Adult Services Intake Form