A Survey for Wisconsin Families Who Have Children with Disabilities or Special Health Care Needs 

We would like to learn a little more about you, your interests and experiences. We will use this information to connect you to opportunities to serve and learn about family leadership. We will also use your answers to help build family connections and opportunities for involvement for families like yours.

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* 1. Today's Date

Date

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* 2. A little more about me:

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* 3. Year of birth of children or young adults with disabilities or special health care needs

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* 4. What conditions or disabilities are of interest to you?

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* 5. Organizational Affiliation (if any)

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* 6. I would like to know more about the following: (Check all that apply)

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* 7. These are some of the systems that I’d like to work on improving:

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* 8. Please indicate areas you have experienced:

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* 9. We would like to learn more about how families prefer to communicate. Please indicate your preferences below:
We may not be able to share information with you in all of the ways listed below at this time.
The best way to communicate with me is:

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* 10. I also like to communicate by:

By completing this questionnaire you will be added to the Family Voices of Wisconsin mailing list and our Family Action Network listserv. Family Voices or your Regional Center for Children and Youth with Special Health Care Needs (CYSHCN) may contact you to follow up on your interests and provide opportunities for family connections and involvement.


To learn more about Family Voices go to www.FamilyVoicesofWisconsin.com

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