Event Registration Form/Registro al Evento

CODSN Summer Kick-Off Family Picnic/Picnic Familiar de Inicio del Verano de la

06/22/2023 04:30 PM - 06:30 PM PT

Admission

Free

Interpretation Support Needed In Spanish / Necesito Servicios de Interpretación 72 hour notice needed/ Se necesita un aviso de 72 hours

CONTACT INFORMATION/ INFORMACIÓN DE CONTACTO

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 - County / Condado: (eg: Crook, Deschutes, Grant, Harney, Jefferson, Klamath, Lake, Wheeler) State/ Estado Primary Role/ Su rol primario Secondary Role/Rol Secundario: Primary Language/ Lenguaje

School District/ Distrito Escolar

Which school district does your child with a disability attend?/ ¿A qué distrito escolar asiste su hijo/a con discapacidad?

Deschutes County/Condado Deschutes: Crook County/Condado Crook: Grant County/Condado Grant: Harney County/Condado Harney: Jefferson County/Condado Jefferson: Klamath County/Condado Klamath: Lake County/Condado Lake: Wheeler County/Condado Wheeler: Other

DEMOGRAPHIC INFORMATION / INFORMACIÓN DEMOGRÁFICA

While the demographic information that you provide is voluntary, the funding sources that support CODSN's work request data periodically./ Aunque la información demográfica que usted proporciona es voluntaria, las agencias que apoyan el trabajo de CODSN piden datos periódicamente.

Ethnic/Racial Identity/Lenguaje Primario:

INFORMATION ABOUT YOUR CHILD/CHILDREN WITH A DISABILITY

Please share more information so that we are able to help you in the future./ Por favor, comparta más información para que podamos ayudarle en el futuro.

Child/Children With A Disability is/Are A Recipient Of/El/los niño/s con discapacidad es/son beneficiario/s de:

Child/Children With A Disability is/Are A Recipient Of 1st Child's Name/Nombre del primer hijo: 1st Child's Year of Birth/Fecha de nacimiento del primer hijo: 1st Child's Ethnic/Racial Identity/Lenguaje Primario:: 1st Child's Primary Disability Diagnosis/Identidad Etnica o Racial del primer hijo: 1st Child's Primary School Eligibility/Diagnostico de Discapacidad Primaria: 2nd Child's Name/Nombre del Segundo hijo: 2nd Child's Year of Birth/ Fecha de nacimiento del segundo hijo: 2nd Child's Ethnic/Racial Identity/Identidad Etnica o Racial del segundo hijo 2nd Child's Primary Disability Diagnosis/ Diagnostico de Discapacidad Primaria del segundo hijo: 2nd Child's Primary School Eligability (IDEA)/Elegibilidad para la escuela (IDEA): Interpretation Support Needed In Spanish / Necesito Servicios de Interpretación If you need accommodations please list them here. 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.

Yes/Sí

required fields