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* Parent Information

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* Child's Name

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* Child's Date of Birth

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* Child's Primary Diagnosis 

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* Preferred way to contact phone/email and time of day

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* Please indicate your preference for a trained volunteer Supporting Parent to match:

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* RELEASE OF INFORMATION:
I give my permission for Families Together, Inc.'s Parent-to-Parent Coordinator to release my name, telephone number and the information I have volunteered on this form to another parent which the Parent-to-Parent Coordinator has screened and trained for a parent match. 

Please indicated that you understand and agree by typing your name and the date below. 

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* CONFIDENTIALITY AGREEMENT 

I pledge not mention names or discuss specific details shared with me by the supporting parent or Parent-to-Parent; and to hold in confidence everything the referred parent tells me, unless specific permission is given by the supporting parent to share the information with others; and understand the exception to this rule is if the information obtained deals with a dangerous situation for the child or family. If I have any questions about confidential information and whether to share it, I will contact the Parent-to-Parent coordinator.



Please indicate that you understand and will adhere by the confidentiality agreement by typing your name and the date below.

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