Event Registration Form/Registro al Evento

Number of people (maximum 2)/Número de personas (2 máximo) 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 | Padre Other Family Member| Otro Miembro de la Familia Foster Parent | Padre Adoptivo Individual w/Disability | Persona con Discapacidad Early Learning and Care Provider/Staff | Personal de atención y Aprendizaje temprano EI/ECSE Provider/Staff | Proveedor y Personal de EI/ECSE K-12 General Education Admin/Educator/Staff | Personal de Educación K-12 General K-12 Special Education - Admin/Educator/Staff | Proveedor/Personal de Educación Especial K-12 Transition Services - Admin/Educator/Staff | Personal de Servicios de Transición ESD Admin/Educator/Staff | Personal de Distrito de Servicios Educativos ESD Higher Education Admin/Educator/Student | Proveedor de Educación más Alta Adult Service Provider | Proveedor de Servicios Adultos Voc Rehab Admin/Staff | Administrador o Personal de Rehabilitación Vocacional DD Services - Brokerage Admin/Staff | Agente DD Services - CDDP Admin/Staff |Proveedor del Programa de discapacidad del desarrollo comunitario CDDP DD Services - DSP/PSW | Proveedor DSP/PSW DD Services - ODDS Admin/Staff | Administrador o Personal de la Oficina de Discapacidades del Desarrollo ODDS Community Partner - General | Socio de la Comunidad General Community Partner - Disability | Socio de la Comunidad Discapacidad Community Partner - Public Policy/Advocacy | Socio de...Abogacion Community Partner - Under-resourced/Underserved | Socio de...Pocos recursos Medical Provider/Staff | Proveedor de Servicio Medico Mental/Behavioral Health Provider/Staff | Proveedor de Salud Mental/Emocional OT/PT/SLP Therapy Provider/Staff | Proveedor de Terapias OT/PT/SLP Local Government Agency Staff | Personal de Agencia Local Gubernamental Local Government Agency Staff - LPHA | Personal de Agência Local Gubernamental de Salud Pública State Government Staff | Personal de Agencia Gubernamental del Estado State Agency Staff - ODE |Personal de Agencia Estatal del Departamento de Educación de Oregon ODE State Agency Staff - OHA | Personal de Agencia Estatal de la Autoridad de Salud de Oregon OHA State Agency Staff - Other | Personal de Agencia Estatal Otro Tribal Partner | Socio Tribal 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 Interpretation Support Needed In Spanish / Necesito Servicios de Interpretación Yes/Si` No If you need accommodations please list them here/Si necesita adaptaciones, indíquelo aquí. 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.