New Membership Registration

CONTACT INFORMATION

Company (If applicable): First Name: Last Name: Address: City: State: Zip: - County: Email: Phone: Primary Role Secondary Role Primary Language Secondary Language

SCHOOL DISTRICT INFORMATION

Which school district does your child attend? If your county does not appear below please leave blank.

Crook County School Districts Deschutes County School District Grant County Harney County Jefferson County Klamath County Lake County Wheeler County

DEMOGRAPHIC INFORMATION

While the demographic information that you provide is voluntary, the funding sources that support CODSN's work request data periodically.

This information is anonymous.

Ethnic/Racial Identity

INFORMATION ABOUT YOUR CHILD/CHILDREN WITH A DISABILITY

Please share more information so that we are able to help you in the future.

Child / Children With A Disability is / Are A Recipient Of 1st Child w/Disability Name 1st Child's Year of Birth 1st w/Disability Ethnic/Racial Identity Child 1 w/Disability Primary Disability Diagnosis Child 1 w/Disability Primary School Eligibility Child 2 w/Disability Name 2nd Child's Year of Birth If Day and Month Are Unknown Child 2 w/Disability Ethnic/Racial Identity Child 2 w/Disability Primary Disability Diagnosis Child 2 w/Disability Primary School Eligability How did you hear about CODSN