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Creating Lives We Love - Growing Stronger Together February 11, 2023
Each person needs to register individually, we need an accurate number for lunch count.
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* Indicates required question
Attendee Name (Nombre)
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Your answer
Address including street number, city, state and zip code
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Your answer
Option 1
Clear selection
Phone number
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Your answer
Email address
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Your answer
Which best describes you?
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Parent of a child with a disability (Padre de un niño con discapacidad)
I am a parent of a child with a disability and a professional in the disability field (Soy padre de un niño con discapacidad y profesional en el campo de la discapacidad)
Professional (Profesional)
Youth (ages 12-26) Juventud (de 12 a 26 años)
What is your ethnicity? (Cuál es tu etnia?)
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Latino or Hispanic (Latino o hispano)
Not Latino or Hispanic (No latino o hispano)
What is your race?
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African American/Black
American Indian/Native American/Native Alaskan
Asian/Indian
Caucasian/White
Hispanic or Latino
Two or more races
¿Cuál es la discapacidad o necesidad médica compleja de su hijo?
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N/A- I am a professional
Autism
Deaf-Blindness
Deafness
Developmental Delay (ECI)
Emotional Disturbance
Hearing Impairment
Intellectual Disability
Multiple Disabilities as categorized by IDEA
Other Health Impairment
Orthopedic Impairment (Physical)
Specific Learning Disability
Speech or Language Impairment
Traumatic Brain Injury
Visual Impairment including Blindness
Child who is inappropriately identified
Child where disability is suspected or not yet identified
Undisclosed
No Disability
What is your child's name? (¿Cuál es el nombre de su hijo?)
Your answer
What is your child's ethnicity? (Cuál es tu etnia?)
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Latino or Hispanic (Latino o hispano)
Not Latino or Hispanic (No latino o hispano)
What is your child's race?
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African American/Black
American Indian/Native American/Native Alaskan
Asian/Indian
Caucasian/White
Hispanic or Latino
Two or more races
Child's Date of Birth (Fecha de nacimiento de su hijo) If Professional, mark N/A
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MM
/
DD
/
YYYY
Professional - What is your job title and company name? (Profesional - ¿Cuál es su puesto de trabajo y el nombre de su empresa?)
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Your answer
What is your primary spoken language? (¿Cuál es su idioma principal hablado?)
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English (Inglés)
Spanish (Español)
Other:
Required
Please choose all that apply to you and your family. (For grant purposes only. This information will not be shared) Elija todas las que se apliquen a usted y su familia. (Solo para fines de subvención. Esta información no se compartirá)
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Foster Care (Orfanato)
Homeless (Sin hogar)
Juvenile Justice (Justicia juvenil)
Low Income (De bajos ingresos)
Migrant (Inmigrante)
Military (Militar)
Native American
Rural
Required
I would like to receive the PACT monthly newsletter. (Me gustaría recibir el boletín mensual de PACT.)
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Yes (Sí)
No
I would like to receive the PACT monthly newsletter. (Me gustaría recibir el boletín mensual de PACT.)
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Yes (Sí)
No
I am interested in learning more about Parent Leadership Training. (Estoy interesado en aprender más sobre la Capacitación de Liderazgo para Padres.)
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Yes (Sí)
No
I am interested in learning more about Youth Leadership Training. (Estoy interesado en aprender más sobre la Capacitación de Liderazgo Juvenil.)
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Yes (Sí)
No
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