Parent Leadership Program 2019 Application Application deadline is February 10, 2019 OK Question Title * 1. Contact Information Name Address Address 2 City/Town State/Province ZIP/Postal Code Email Address OK Question Title * 2. Home Phone Number OK Question Title * 3. Mobile Phone Number OK Question Title * 4. The area where I live is: Urban Suburban Rural OK Question Title * 5. Are there any special accommodations necessary for you to participate? Yes No OK Question Title * 6. If yes, please specify (e.g., accessibility, interpreter, transportation, etc.) OK Question Title * 7. Please confirm your commitment to the Parent Leadership Program by initialing each of the expectations on the space provided by checking the box next to it. I agree to attend two of the in-person sessions scheduled March 2, April 6, May 4 or June 1 I will participate in the evaluation process by completing the evaluation forms and giving feedback. I agree to complete the additional required independent learning opportunities totaling 8 hours. I understand that excused absences must be approved by the Parent Leader Program Coordinator. I will maintain confidentiality for families to whom I provide advocacy assistance. I agree to be in contact with Parent Network of WNY on a quarterly basis. OK Please fill out the following questionnaire. The information provided will help Parent Network of WNY select participants. OK Question Title * 8. Why are you interested in the Parent Leadership Program? OK Question Title * 9. What skills/knowledge do you bring to the program? OK Question Title * 10. What skills/knowledge do you hope to gain from the program? OK Question Title * 11. Have you participated in any groups (parent groups, committees, etc)? OK DONE