Parent Match Program: Volunteer Application Survey

Thank you so much for your interest in becoming a Support Parent in our Parent Match program. All the information you provide on this form will be kept confidential and will help us find the best possible match for families who are seeking support. Our Parent Match Program is one of several ways Vermont Family Network supports families. You can read more about the Support Parent role and responsibilities here. After we review your application, we will invite you to a complete a webinar to learn more about how to be an effective Support Parent. This is a new training that we plan to role out this fall (2020). In the meantime, if you have any questions, please contact Mindy.deibler@vtfn.org

1.Your Contact Information(Required.)

Full Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

2.What language do you feel most comfortable speaking?

3.What other language(s) do you speak fluently?

5.(Optional) Are you of Latino or Hispanic decent?

Yes

Unsure

6.(Optional) Do you consider yourself to be a New American immigrant?

Yes

Unsure

7.How did you hear about Vermont Family Network's Parent Matching Program?(Required.)

9.Information About Your Child with a Disability or Special Health Care Need(Required.)

Full Name

Date of Birth

Self-identified Gender

Primary Diagnosis

Secondary Diagnoses

11.(Optional) Is your child with a special health care need/disability of Latino or Hispanic decent?

Yes

Unsure

12.What else would you like us to know about your child with a special health care need/disability?

13.(Optional) Other Children in the Household

Full Name(s)

Date(s) of Birth

Self-identified Gender(s)

Diagnoses (if any)

14.What else would you like us to know about other children in the household?

15.Is there anything unique about your family structure, culture, or interests that would help us make an appropriate match with another parent?

16.Why do you want to become a Support Parent?(Required.)