Application deadline is February 10, 2019

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* 1. Contact Information

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* 2. Home Phone Number

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* 3. Mobile Phone Number

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* 4. The area where I live is:

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* 5. Are there any special accommodations necessary for you to participate?

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* 6. If yes, please specify (e.g., accessibility, interpreter, transportation, etc.)

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* 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.

Please fill out the following questionnaire. The information provided will help Parent Network of WNY select participants.

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* 8. Why are you interested in the Parent Leadership Program?

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* 9. What skills/knowledge do you bring to the program?

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* 10. What skills/knowledge do you hope to gain from the program?

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* 11. Have you participated in any groups (parent groups, committees, etc)?

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