Event Registration Form/Registro al Evento

Number of Attendees / Numero asistiendo First Name/ Nombre Last Name/ Apellido Email /Correo electrónico Primary Phone/Teléfono Address/Domicilio City/ Ciudad Zip / Código Postal - Zip Suffix 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 Primary Language/ Lenguaje American Sign Language (ASL) Arabic Chinese-Cantonese Chinese-Mandarin English Hindi Japanese Korean Romanian Russian Somali Spanish Vietnamese Other Unknown 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 Year of Birth/Fecha de nacimiento del primer hijo: 1st Child's Primary Disability Diagnosis/Diagnostico de Discapacidad Primaria del primer hijo 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 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