Event Registration Form/Registro al Evento

Number of Attendees / Number asistiendo Company if applicable/ Compañía si aplica First Name/ Nombre Last Name/ Apellido Email /Correo electrónico Primary Phone/Teléfono Address/Domicilio City/ Ciudad Zip / Código Postal - Zip Suffix County / Condado: (eg: Crook, Deschutes, Grant, Harney, Jefferson, Klamath, Lake, Wheeler) State/ Estado Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Primary Role/ Su rol primario Parent/ Primary Caregiver/ Cuidador principal Other Family Member| Otro Miembro de la Familia Foster Parent | Padre Adoptivo Individual w/Disability | Persona con Discapacidad Special Education - Admin/Educator/Staff | Proveedor/Personal de Educación Especial General Education Admin/Educator/Staff | Personal de Educación Early Learning/ EI/ECSE/ and Care Provider/Staff | Personal de atención y Aprendizaje temprano Transition Services - Admin/Educator/Staff | Personal de Servicios de Transición Community Partner - Disability | Socio de la Comunidad Discapacidad Community Partner - General | Socio de la Comunidad General Tribal Partner | Socio Tribal Tribal Family (only use as a secondary role)| Familia tribal o familia nativa (Úselo solo como rol secundario) Other | Otro Secondary Role/Rol Secundario: Parent/Primary Caregiver | Padre Other Family Member| Otro Miembro de la Familia Foster Parent | Padre Adoptivo Individual w/Disability | Persona con Discapacidad Special Education - Admin/Educator/Staff | Proveedor/Personal de Educación Especial General Education Admin/Educator/Staff | Personal de Educación Early Learning/ EI/ECSE/ and Care Provider/Staff | Personal de atención y Aprendizaje temprano Transition Services - Admin/Educator/Staff | Personal de Servicios de Transición Community Partner - Disability | Socio de la Comunidad Discapacidad Community Partner - General | Socio de la Comunidad General Tribal Partner | Socio Tribal Tribal Family (only use as a secondary role) Familia tribal o familia nativa(Úselo solo como rol secundario) Other | Otro Primary Language/ Lenguaje American Sign Language (ASL) Arabic Chinese-Cantonese Chinese-Mandarin English Hindi Japanese Korean Romanian Russian Somali Spanish Vietnamese Other Unknown Crook County/Condado Crook: Crook County SD Deschutes County/Condado Deschutes: Bend La Pine Admin SD 1 Redmond SD 2J Sisters SD 6 Grant County/Condado Grant: Dayville SD 16J John Day SD 3 Long Creek SD 17 Monument SD 8 Prairie City SD 4 Harney County/Condado Harney: Diamond SD 7 Double O SD 28 Drewsey SD 13 Frenchglen SD 16 Harney County SD 3 Harney County SD 4 Pine Creek SD 5 South Harney SD 33 Suntex SD 10 Jefferson County/Condado Jefferson: Ashwood SD 8 Black Butte SD 41 Culver SD 4 Jefferson County SD 509J Warm Springs K8 Academy Klamath County/Condado Klamath: Klamath County SD Klamath Falls City Schools Lake County/Condado Lake: Adel SD 21 Lake County SD 7 North Lake SD 14 Paisley SD 11 Plush SD 18 Wheeler County/Condado Wheeler: Fossil SD 21J Mitchell SD 55 Other/ Otro Ethnic/Racial Identity/Identidad étnica/racial: African American/Black American Indian/Alaskan Native Asian Caucasian/White Hawaiian/Pacific Islander Hispanic/Latino Multiracial Russian/East European Other Prefer not to disclose Unknown 1st Child's Ethnic/Racial Identity/Identidad étnica/racial del primer hijo: African American/Black American Indian/Alaskan Native Asian Caucasian/White Hawaiian/Pacific Islander Hispanic/Latino Mutiracial Russian/East European Other 2nd Child's Ethnic/Racial Identity/Identidad Etnica o Racial del segundo hijo African American/Black American Indian/Alaskan Native Asian Caucasian/White Hawaiin/Pacific Islander Hispanic/Latino Mutiracial Russian/East European Other 1st Child's Name/Nombre del primer hijo: 1st Child's Year of Birth/Fecha de nacimiento del primer hijo: 1st Child's Primary Disability Diagnosis/Diagnóstico primario de discapacidad del primer niño: ADD/ADHD Autism Spectrum Disorders Autism/Down Syndrome Autism/Cerebral Palsy Autism/ Emotional - Behavioral Disability Autism/Intellectual Disability Blind Visual Impairment Cerebral Palsy Communication Disorders/Speech and Language Impairments Deaf/Blindness Deaf/Hearing Impairment Developmental Disability Down Syndrome Dyslexia Emotional - Behavioral Disabilities Fetal Alcohol Syndrome Fragile X Syndrome Intelectual Disability Learning Disability Medical Conditions/Special Health Needs Mental Health Multiple Disabilities Physical Disabilities Post Traumatic Stress Disorder Rare Disorders Rett Syndrome Seizure Disorder/Epilepsy Sensory Processing Disorder Tourette Syndrome Traumatic Brain Injury Unknown or not Provided No Disability 2nd Child's Name/Nombre del Segundo hijo: 2nd Child's Year of Birth/ Fecha de nacimiento del segundo hijo: 2nd Child's Primary Disability Diagnosis/ Diagnostico de Discapacidad Primaria del segundo hijo: ADD/ADHD Autism Spectrum Disorders Autism/Cerebral Palsy Autism/Down Syndrome Autism/ Emotional - Behavioral Disability Autism/Intellectual Disability Blind/Visual Impairment Cerebral Palsy Communication Disorders/Speech and Language Impairments Deaf/Blindness Deaf/Hearing Impairment Developmental Disability Down Syndrome Dyslexia Emotional - Behavioral Disabilities Fetal Alcohol Syndrome Fragile X Syndrome Intellectual Disabilty Learning Disability Medical Conditions/Special Health Needs Mental Health Multiple Disabilities Physical Disabilities Post Traumatic Stress Disorder No Disability Rare Disorders Rett Syndrome Seizure Disorder/Epilepsy Sensory Processing Disorder Tourette Syndrome Traumatic Brain Injury Unknown or not Provided Child/Children With A Disability is/Are A Recipient Of/El niño/los niños con discapacidad es/son beneficiarios de If you need accommodations please list them here. Interpretation Support Needed In Spanish / Necesito Servicios de Interpretación Yes/Si` No Photo/video Release - I/We hereby give consent to Central Oregon Disability Support Network (CODSN ) and all programs under CODSN to photograph or Video our child/self to educate others about the programs and services offered by CODSN. Among the uses contemplated are illustration of articles in newsletters, TV news articles, in profiles that contributors receive, in brochures, to illustrate services discussed on the website, in displays at community fairs, to publicize local programs, to make professional presentations, and to publicize the equipment and teaching methods used. In giving approval, I/we understand it is without consideration of compensation of any kind, and CODSN is released from any claims or liability. Captcha