* 1. Contact Information

* 2. How Did You Hear About the Special Needs Parent Committee?

* 3. Age of Child with Disability: __________ Grade In School: _________

* 4. Does Your Child Have?

* 5. Please select the top 4 workshops/discussions you would be likely to attend

* 6. How many workshops a year do you believe we should sponsor (topic driven)

* 7. How many workshops would you anticipate attending each year (topic drive)?

* 8. How many general meetings do you believe we should sponsor (i.e. open discussion, support, less topic driven)

* 9. When are you most likely able to attend a workshop?

* 10. Would you be willing to serve in a leadership position?

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