Registration - Providing Professionals Real Life Family Experiences

If you are a parent of a child with a neurodevelopmental disability* AND live in southeastern South Dakota (Brookings, Sioux Falls, Beresford, Yankton, Vermillion, Dakota Dunes and surrounding communities) you can impact future medical and service professionals by helping them experience and understand the family perspective.

*Developmental disabilities are a wide group of conditions due to an impairment in physical, learning, language, or behavior areas. These conditions begin during the developmental period, may impact day-to-day functioning, and usually last throughout a person’s lifetime. Specific conditions include (but are not limited to ) ADHD, Autism Spectrum Disorders, Cerebral Palsy, Down Syndrome, Fetal Alcohol Spectrum Disorders, Fragile X Syndrome, Hearing Loss, Kernicterus, Muscular Dystrophy, Tourette Syndrome, and Vision Impairment.

If you are interested in participating, please complete this brief questionnaire. SD Parent Connection will follow up with you.

Confidentiality/privacy of family information will be honored. Participating families are free to opt out at any time.

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* 1. Thank you for your interest. What do you hope to achieve by participating in this experience?

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* 2. Parent(s)

Name:

Address:

Address 2:

City,State:

ZIP:

Email Address:

Phone Number:

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* 3. Please provide the name, age and any special needs of your child.

Child One:

Age:

Any special needs/allergies/etc:

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* 4. Please provide the name, age and any special needs of your child.

Child Two:

Age:

Any special needs/allergies/etc:

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* 5. Please provide the name, age and any special needs of your child.

Child Three:

Age:

Any special needs/allergies/etc:

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* 6. Please list additional children below, with their ages and special health care needs, if any:

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* 7. Please mark what services your child(ren) is/are receiving (does not have to be school based):

Occupational Therapy

Physical Therapy

Speech-Language Pathology

Transportation

Audiological Services

Interpreting Services

Therapeutic Recreation

Counseling

Orientation and Mobility

Medical Services

School Nurse/School Health Services

Assistive Technology

Birth to Three Services

Special Education Services

Other (please specify)

Registration - Providing Professionals Real Life Family Experiences

Question Title

* 1. Thank you for your interest. What do you hope to achieve by participating in this experience?

Question Title

* 2. Parent(s)

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* 3. Please provide the name, age and any special needs of your child.

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* 4. Please provide the name, age and any special needs of your child.

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* 5. Please provide the name, age and any special needs of your child.

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* 6. Please list additional children below, with their ages and special health care needs, if any:

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* 7. Please mark what services your child(ren) is/are receiving (does not have to be school based):

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* 8. What would be the best way for a student to contact you to schedule a "family experience?"

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* 9. Is there any other information you would like to share? Do you have any questions?