1.Date

2.Personal Information

Name

Address

Address 2

City/Town

State

ZIP

Country

Email Address

Phone Number

3.Preferred method of contact

4.Are you? (check all that apply)

parent with a disability

parent of a child with a disability under the age of 14

parent of a child with a disability over the age of 14

guardian

foster parent

family member

5.Are you the parent or family member of a child or, foster child with a disability or special healthcare needs 0 to 26 years of age?

Yes

No

6.What is your child's:

Age:

Disability:

School District:

School:

7.Can you commit 2 to 3 hours per month to the Parent Advisory Council?

Yes

No

8.b'Would you be interested in a virtual support group?'

Yes

No

9.Tell us about yourself. What unique experiences, perspectives, talents, or skills could you bring to the council?

10.Why do you want to be a member of the PAC?

11.How do you define parent or family engagement?

12.As a PAC member, what would you most like to learn about?