Scholarship Application

Thank you for your interest in attending the 18th Annual Family Leadership Conference on April 13th, 2023 at the Embassy Suites, 1000 Woodward Pl NE, Albuquerque, NM 87102.

Scholarships are on a first come first serve basis and reserved for parents or caregivers of a child with a disability, medical complexity, or at-risk for developmental delay and youth with disabilities ages birth-26. A priority will be given to first-time attendees.

If you have any questions or concerns, please call our office at 505-247-0192 or email conference@parentsreachingout.org

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* 1. Contact Information:

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. I am a: 

Parent 

Legal Guardian 

Foster Parent 

Grand-Parent 

Relative 

Other (please specify)

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* 3. Spouse Information (Write N/A if they will not be attending the conference with you)

First Name:

Last Name:

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* 4. Ethnicity:

Hispanic or Latino

Non Hispanic or Non Latino

Prefer not to answer

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* 5. Race:

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Two or more races

Prefer not to answer

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* 6. Language Preference: 

English 

Spanish 

Other:

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* 7. Please list the total number of people you are including in your scholarship application (Only list those who will be attending the conference):

Adults:

Children:

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* 8. List all children that will be attending the conference with you including date of birth:

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* 9. Does your child have a disability, medical complexity, or is at risk for developmental delay?

Yes

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* 10. If “yes” please specify and provide additional information about your child’s condition:

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* 11. Have any of your children received Early Intervention (EI) Services?

Yes

Scholarship Application

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* 1. Contact Information:

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* 2. I am a: 

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* 3. Spouse Information (Write N/A if they will not be attending the conference with you)

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* 4. Ethnicity:

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* 5. Race:

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* 6. Language Preference: 

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* 7. Please list the total number of people you are including in your scholarship application (Only list those who will be attending the conference):

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* 8. List all children that will be attending the conference with you including date of birth:

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* 9. Does your child have a disability, medical complexity, or is at risk for developmental delay?

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* 10. If “yes” please specify and provide additional information about your child’s condition:

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* 11. Have any of your children received Early Intervention (EI) Services?

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* 12. If “yes”, What agency:

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* 13. Tell us about any challenges you have experienced in navigating early intervention, special education, or healthcare: