Training Registration

*In which county of New York State do you live:
Select One Albany Allegany Bronx Broome Cattaraugus Cayuga Chautauqua Chemung Chenango Clinton Columbia Cortland Delaware Dutchess Erie Essex Franklin Fulton Genesee Greene Hamilton Herkimer Jefferson Kings Lewis Livingston Madison Monroe Montgomery Nassau New York Niagara Oneida Onondaga Ontario Orange Orleans Oswego Otsego Putnam Queens Rensselaer Richmond Rockland St. Lawrence Saratoga Schenectady Schoharie Schuyler Seneca Steuben Suffolk Sullivan Tioga Tompkins Ulster Warren Washington Wayne Westchester Wyoming Yates Not in New York State

My relationship with a Person with Special Need is as a:
Select One Parent/Caregiver Professional Other

*If you answered the above question with "Parent/Caregiver", are you a Support Parent through your regional office of Parent to Parent of NYS?   
Select One Yes No Not Sure Not Applicable

*For which training are you registering? Select One Advocacy Skills and Techniques Health Care Record Keeping Home Medical Care Parent-Professional Collaboration

First Name: *Last Name:

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.

*Address:

City: State: Zip:

*Email Address:

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: