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Family Empowerment Program 2027 Application
Thank you for your interest in this great series of learning opportunities. Shortly after your submission you will receive an email notification of your status.
OK
1.
Contact Information
Name
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Email Address
2.
Home Phone Number
3.
Mobile Phone Number
4.
The area where I live is:
Urban
Suburban
Rural
5.
Are you a parent, family member, caregiver or guardian of an individual with a disability?
Yes
No
6.
Does your child have a developmental disability and lives with family?
Yes
No
7.
Age range of child
0-2
3-5
6-11
12-14
15-18
19-26
27+
8.
Please confirm your commitment to the Family Empowerment Program by initialing each of the expectations on the space provided by checking the box next to it.
I agree to attend/participate in the virtual sessions via zoom. Saturday, January 16 from 9 am to 1 pm. Thursdays from 6:00 pm to 7:30 pm on January 21, 28, February 4, 11, 18, 25, and March 4.
I agree to do the independent work as required.
I will participate in the evaluation process by completing the evaluation forms and giving feedback.
Please fill out the following questionnaire. The information provided will help Parent Network of WNY select participants.
9.
Why are you interested in the Family Empowerment Program?
10.
What skills/knowledge do you bring to the program?
11.
What skills/knowledge do you hope to gain from the program?
12.
Have you participated in any groups (parent groups, committees, etc)?
PHOTO/VIDEO PERMISSION AND RELEASE FORM
13.
Photo/Video Permission & Release Form
Video Recordings
- I give permission to Parent Network of WNY to videotape me and/or my child(ren) and to use the videotape for general education (e.g. about the agency, children and adults with disabilities, or for fund-raising purposes).
Photographs & Images
- I give permission to Parent Network of WNY to videotape me and/or my child(ren) and to use the videotape for general education (e.g. about the agency, children and adults with disabilities, or for fund-raising purposes).
Name Usage
- I grant permission to Parent Network of WNY for the use of my name for Parent Network publications such as but not exclusive to; news articles, newsletters, event promotions, etc.
Personal Stor
y - I grant permission to Parent Network of WNY to use my story for general education (e.g. website, curriculum, fund-raising purposes).
I do not consent to release my name, image, story or video.
14.
I do not wish to complete this form at this time and will discuss with the program coordinator.
Yes
No
15.
In the box below, please identify any specific information or images that you do not want shared AND/OR any medium on which you do not want your information or images to be shared. If no limitations, write none.
Current Progress,
0 of 15 answered
