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Name*

First Last

Your Child's Name*

First Last

Your Child's Date of Birth*

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Address*

Street Address City State ZIP Code

Home Phone*

Cell Phone

Email*

Preferred Method of Contact

Name of other Parent/Guradian

First Last

Phone number of other Parent/Guardian

How can we support you?

How can our team best support you?

What is your child's grade level and what school does your child attend?

How did you learn about our programs?

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 require any accommodations for participating with SNSC?

Declaration & Permissions

Yes,*

I hereby give my permission for Special Needs Support Center to collect and store my personal information.

Yes,*

I consent to the unrestricted use by the Special Needs Support Center (SNSC) of photographs taken, in whole or in part, unlimited use, for all purposes in any form or medium, including its use through or on any electronic media, including the internet. I also consent to the unrestricted use by SNSC of any corresponding text or audio associated with the pictures. I waive any right to inspect or approve the finished product or products that may be used with the finished photograph(s), including any narrative text that may go along with the photograph. I hereby release SNSC from any and all claims in connection with the photograph(s) and/or corresponding text or audio, including any and all claims of libel.

Yes,*

I understand that my personal information may be shared with team members at Special Needs Support Center if necessary.

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Interested in joining one of our programs? Fill out this form to get started!

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Name of the person signing up for Adult Services*

First Last

Date of Birth

MM slash DD slash YYYY

Address*

Street Address City State ZIP Code

Home Phone*

Cell Phone

Email*

Preferred Method of Contact

Name of Parent/Guardian

First Last

Phone number Parent/Guardian

Email of Parent/Guardian

How can we support you?

What is your major concern right now?

How can our team best support you?

How did you learn about our programs?

Tell us about yourself.

What are your hobbies, special interests, and skills?

Do you receive support from a local agency? If so, please tell us more about the support you receive.

Do you have a known diagnosis or a disability? Please tell us more.

Do you require any accommodations for participating with SNSC?

Which of these do you identify as? (Check all that apply)

Indigenous

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Hispanic

Middle Eastern

White

Other

Declaration & Permissions

Yes,*

I hereby give my permission for Special Needs Support Center to collect and store my personal information.

Yes,*

I confirm that I want to enroll in SNSC’s Adult Services and Programs.

Yes,*

I understand that my personal information may be shared with team members at Special Needs Support Center if necessary.

Yes,*

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Get Support

Need advocacy, resources, or direct support? Let us know how we can help!

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Your Name*

First Last

Your Date of Birth*

MM slash DD slash YYYY

Address*

Street Address City State ZIP Code

Home Phone*

Cell Phone

Email*

Preferred Method of Contact

Emergency Contact

First Last

Phone number of Emergency Contact

How 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?

Tell us about yourself

What are your hobbies, special interests, and skills?

Do you receive support from a local agency? If so, please tell us more about what support you receive.

Does you have a known diagnosis or a learning disability? Please tell us more.

Which of these do you identify as? (Check all that apply)

Indigenous

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Hispanic

Middle Eastern

White

Other

Do you receive any services now?

Do you require any accommodations for your meeting with SNSC?

Declaration & Permissions

Yes,*

I hereby give my permission for Special Needs Support Center to collect and store my personal information.

Yes,*

I hereby give SNSC permission to add my contact information to newsletter distribution and updates on emails

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.

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Connect Now

How can we support you?

Tell us about your child.

Declaration & Permissions

How can we support you?

Tell us about yourself.

Declaration & Permissions

How can we support you?

Tell us about yourself

Declaration & Permissions