Parent To Parent of NYS

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Request a Parent Match

If you live in New York State and would like to be matched with a Support Parent, please complete the form below.

We will act on your request as quickly as possible, however, please keep in mind that our Coordinators are parents themselves and most work on a part-time basis.  You may follow-up on this request by phoning your Regional Office if you feel it is necessary.



FAMILY INFORMATION

Parent's (or Caregiver's) Information

*In which county of New York State do you live:




First Name: *Last Name:

Address:

City: State: Zip:

*Home Phone: ()

Best Time to Reach Me at Home:

Is it OK for us to call you at work? Yes No

Work Phone: ()

Best Time to Reach Me at Work:


*Email:



Languages:




Person With Special Health Care Need or Disability

We will protect all information that is provided to Parent to Parent including names, addresses, phone numbers, birthdates and medical information.  For details see our Privacy Statement.

First Name: Last Name:

DOB:// (mm/dd/yy)

Sex:

List all disabilities or conditions
Other children names and ages


Please include any additional information about your child that might assist in making a good match, i.e., twins, disability the result of an accident, play/social skills, hobbies/interests, etc.  If you would like to speak to another parent about a specific topic related to your child, please indicate.


Please include any special issues or concerns you may have regarding your child.


I would like to be contacted by Parent to Parent of NYS to explain my request further.



Parent to Parent has my permission to release my name, phone number and/or Email address to a trained support parent in order to complete this request for a parent match.
Yes No