Your Child, Your Choice Program Registration

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* 1. Please provide your name, address, email address, and telephone number.

Name: *

Address: *

Address 2:

City/Town: *

ZIP: *

Email Address: *

Phone Number: *

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* 2. Child/Children's name(s)
Age
Grade

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* 3. I am participating as a:

Parent

Professional

Advocate

Other

Other (please specify)

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* 4. What type of non-traditional school does your child currently attend?

Parochial School

Cyber-Charter School

Charter School

Private School

Private Specialized School

Home School

Other

Traditional School

Other (please specify)

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* 5. School name and location

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* 6. IDEA lists 13 categories of disability. Which category best describes your child's disability?

autism

deaf-blindness

deafness

emotional disturbance

hearing impairment

intellectual disability

multiple disabilities

orthopedic impairment

other health impairment

specific learning disability

speech or language impairment

traumatic brain injury

visual impairment (including blindness).

Comments

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* 7. One of the goals of this project is to provide training to parents and professionals to allow them to be active leaders in their community. How do you plan to use your skills after the completion of the project?

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* 8. The majority of our training's for this program will be offered on-line. Are you comfortable with your ability to access the internet regularly, view webinars, share documents and take part in Facebook conversations?

Yes

I would like to speak with someone this question

Other (please specify)

Question Title

* 1. Please provide your name, address, email address, and telephone number.

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* 2. Child/Children's name(s)AgeGrade

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* 3. I am participating as a:

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* 4. What type of non-traditional school does your child currently attend?

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* 5. School name and location

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* 6. IDEA lists 13 categories of disability. Which category best describes your child's disability?

Question Title

* 7. One of the goals of this project is to provide training to parents and professionals to allow them to be active leaders in their community. How do you plan to use your skills after the completion of the project?

Question Title

* 8. The majority of our training's for this program will be offered on-line. Are you comfortable with your ability to access the internet regularly, view webinars, share documents and take part in Facebook conversations?

Question Title

* 9. Please tell us how you hear about this program.

* 2. Child/Children's name(s)
Age
Grade