First Name *

Last Name *

Email

Phone 1

Address Line 1

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City

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Zip/Postal Code

County *

Primary Role * 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

1st Child's Year of Birth

1st Child's Primary Disability Diagnosis 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

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