Name:
Street Address:
City:
County:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
E-Mail:
1. Does your child have disabilities? (If No, please go to Question 2.)
a. If so, please indicate your child's disability and provide information about how it impacts your child's daily life:
b. What kinds of support services or technology services (e.g. devices) does your child use or have?
c. What services does your child receive from the county where you live?
2. Fill in one or more in each column for each child with autism or other disabilities:
Child 1:
Child 2:
Child 3:
a. Please specify by child his/her disability and say how the disability affects his/her daily life and that of his/her family:
b. Is your child receiving special education services from the school where he/she attends?
c. Specify the special education services your child receives from the school district:
3. Identify one or two specific problems or issues that are of greatest concern to you.
4. All classes begin with check-in at 3:30pm and end at 7pm.
a. Attendance is required at each signed up class. Will you will make a time commitment for each class?
5. Do you require interpreter services?
6. As a parent, will you be using respite/child care services so can you participate in the training?
7. As a parent, will you need transportation so you can participate in the training?
8. Are you currently involved in volunteering or in an advocacy organization?
9. Tell us why do you want to participate in the Diverse Cultural Parents Training Autism Series:
10. How did you learn about the Cultural Innovative Disability Autism Training for Parents?
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