Support Parent Application Demographics Thank you for being willing to share your information with PHP and your experience with another parent! This information is updated in PHP's client records which is confidential. PHP does not release your information to a mentee without your permission. Our protocol for matching is to call you to see if it is a good time for you to act as a support parent. We then provide you the contact information about the other parent (with permission). We ask for follow up to your contact to ensure a good match has occurred.If you have never attended a support parent training, we ask that you do our Online Support Parent Training found at Online Support Parent Training Question Title * 1. I have watched all the videos and read the materials and agree to be contacted by Parents Helping Parents regarding matching me to a parent requesting a support parent. Question Title * 2. Please enter the following information. Name: * Address: * Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: * Daytime Phone Number: Question Title * 3. Your child's school district (if applies) Question Title * 4. I have direct experience with Past Present Don't know what this is IFSP (Individualised Family Service Plan) children ages 0-3 IFSP (Individualised Family Service Plan) children ages 0-3 Past IFSP (Individualised Family Service Plan) children ages 0-3 Present IFSP (Individualised Family Service Plan) children ages 0-3 Don't know what this is IEP (Individualized Education Plan)children ages 3-22 IEP (Individualized Education Plan)children ages 3-22 Past IEP (Individualized Education Plan)children ages 3-22 Present IEP (Individualized Education Plan)children ages 3-22 Don't know what this is Post Secondary Special Education (18-22) Post Secondary Special Education (18-22) Past Post Secondary Special Education (18-22) Present Post Secondary Special Education (18-22) Don't know what this is Regional Center Services Regional Center Services Past Regional Center Services Present Regional Center Services Don't know what this is Department of Rehabilitation Department of Rehabilitation Past Department of Rehabilitation Present Department of Rehabilitation Don't know what this is SSI - Supplemental Security Income SSI - Supplemental Security Income Past SSI - Supplemental Security Income Present SSI - Supplemental Security Income Don't know what this is Question Title * 5. Under what category do you best identify your child's condition? Attention Deficit (Hyperactivity) Disorder Autism Spectrum Disorder Blind Deaf/Hard of Hearing Health Impairment, i.e., asthma, cancer, epilepsy, etc. Intellectual / Cognitive Impairment Learning Difference Mental Health Mood Disorder Multiple Orthopedic Speech or Language Substance Abuse Traumatic Brain Injury Other (please specify) Question Title * 6. What is your child's primary condition, followed by other secondary issues s/he may have. Question Title * 7. Your Child's Age Question Title * 8. List treatments, procedures, or surgeries that your child has had that you would be willing to talk about with another parent. Question Title * 9. Does your child use any adaptive equipment or assistive technology? If so, which. Question Title * 10. Is your child taking medications? If so, please describe Question Title * 11. Please list the area's that you have knowledge in related to special needs. For example: G-tubes, IHSS, Special Diets, etc.: Question Title * 12. Select languages you speak fluently (other than English) Afghani African* Amharic Arabic Armenian American Sign Language Assyrian Bengali Bosnian Bulgarian Cambodian Cantonese Czech Dhakkai Dutch English Ethopian Farsi Finnish French German Greek Gujarati Hebrew Hindi Hmong Hungarian Igbo (Nigerian) Ilonggo Ilocano Indonesian Italian Japanese Kannada (India) Kapampangan Khowar Konkoni Korean Krio Kutchi Laotian Lebanese Malayalam Mandarin Marathi Nepalese Oriya Oromo Pashtu Persian Polish Portuguese Punjabi Romanian Russian Samoan Signing Exact English Singhalese Slovak Somali Sourashtra SP Spanish Swahili Swedish Tagalog Taiwanese Tamil (India) Telagu (Indian) Thai Tigrygna Tongan Turkish Unknown Urdu Vietnamese Visayan Yiddish Other (please specify) Question Title * 13. What additional training or workshops have you attended? Question Title * 14. What is your enthicity? Hispanic Not Hispanic Question Title * 15. Please tell us the race you identify with African American Black Asian Caucasian Hispanic/Latino Mutliracial Native American/Alaskan Pacific Islander Other, please specify Other (please specify) Question Title * 16. In one paragraph, tell us why you felt called to become a support parent. Done
