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Become a Support Parent Form

If you would like to become a Support Parent, please complete and submit the form below.  Once we receive your completed Support Parent Form you will be contacted by a Coordinator from your Regional Office.

Support Parent Family Information Form

If you are a parent or primary caregiver of an individual with special needs, reside in the state of New York, and would like to provide emotional support and information to other families facing challenges similar to what you have experienced, please fill in the form below.  Submit only the information you are comfortable with providing. (Contact information is required).  All information is kept confidential.



FAMILY INFORMATION
Parent/Caregiver

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



I would prefer to complete my Support Parent Training by:


*First Name: *Last Name:

Relationship to child:

Address:

City: State: Zip:

*Home Phone: ()

Best Time to Reach Me at Home:

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

Work Phone: ()

Best Time to Reach Me at Work:

Fax: ()

*Email:

Race:

Languages:



Person With Special Need

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:

When was disability diagnosed?
Before Birth
After Birth
At the age of

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.



Please include any special issues or experience you may have regarding your child that may help other families.


Parent to Parent has my permission to release my name and phone number to another parent asking for support.
Yes
No