LEADers 1.0 Training Fall 2020

If you need any assistance or have any questions, email Heather Luke at heather@ppmd.org or Rene Averitt-Sanzone at rene@ppmd.org.

There will be additional opportunities to network/connect with others in your community to support you as you prepare to use the skills learned in this training to support others.

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* 1. Please provide your contact information.

First Name: *

Last Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *

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* 2. In what county of Maryland do you live?

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* 3. Are you Hispanic?

Yes

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* 4. What is your race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

Multiple races

Other (please specify)

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* 5. Please tell us about your child(ren) with a disability.

	Age	Disability
Child 1	Child 1 Age menu	Child 1 Disability menu
Child 2	Child 2 Age menu	Child 2 Disability menu
Child 3	Child 3 Age menu	Child 3 Disability menu
Child 4	Child 4 Age menu	Child 4 Disability menu

Other (please specify)

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* 6. Where does your child attend school?

Public school

Non-public school (paid by the school system)

Private school (paid by the family)

Maryland School for the Deaf

Home schooled

Other (please specify)

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* 7. Please tell us briefly what you hope to gain from the training?

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* 8. How will you use the information learned in this training?

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* 9. I am committed to attend all training dates.

Yes

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* 10. I understand that I will be expected to volunteer, at a minimum, 12 hours by using the skills learned during this training to support other families. We ask that you complete this within 12 months.

Yes

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* 11. Do you need a sign language interpreter?

Yes

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* 12. Do you have any other language needs (i.e. French, Chinese, Mandarin, Large Print, etc.)

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* 13. ACCOMMODATIONS: Please tell us any accommodations that you require (including dietary). Please note that we will try to make reasonable accommodations but you may need to consider bringing food you are confident will meet your needs. (We will need this information in case we can ever meet in person.)