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Support Group Registration
Support Group for Parents of Black Children with Disabilities
Monthly
6:00-7:30pm
Online via Zoom
OK
*
1.
Registration
(Required.)
First & Last Name
*
Address
*
Address 2
City
*
State
*
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
*
Email Address
*
Phone Number
*
*
2.
Please indicate whether you are one of the following:
(Required.)
Parent/Guardian
Caregiver
Advocate/Professional
Other/Otro (please specify)
*
3.
Please describe your race/ethnicity.
(Required.)
White or Caucasian
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Two or more races
Decline to answer/Negarse a responder
Other/Otro (please specify)
*
4.
Please select your child's disabilities.
(Required.)
ADD/ADHD
Autism Spectrum Disorder
Deaf-Blindness
Developmental Delay
Emotional Disturbance
Gifted
Hearing Imp. (Including Deafness)
Intellectual Disability
Multiple Disablities
No IDEA Disability
Orthopedic Impairment (Physical)
Other Health Impairment
Specific Learning Disability
Speech Language Impairment
Suspected/Undiagnosed
Traumatic Brain Injury
Visual Impairment (including blindness)
Other (please specify)
*
5.
What is your child/children's age(s)?
(Required.)
6.
What are you hoping to get out of this support group?
7.
Do you require any accommodations? If so, please specify.
8.
How did you hear about Show and Tell?
