Family Biographical Information

Parent Consultant Directory

Please complete this form by Friday, February 27, 2004. When finished, press the submit button at the bottom of page two. Your completed work will be sent to Lynn Havemann. If you've received a hard copy of this form, feel free to mail it back using the address on the consent form.

Parent Name(s):

Children/Youth Names:

Year of Birth:

CHILD(REN) WITH SPECIAL NEEDS INFORMATION: (please do not use abbreviations unless you explain them).

1. Child(ren)'s Name(s):

2. Tell us about your child(ren)'s circumstances (consider condition(s)/special needs, strengths/challenges, special equipment, etc):

3. School, Early Intervention Program or Community-Based Program your child(ren) currently attends (if applicable):

PARENT INFORMATION:

1. If just one parent is interested in being a consultant, which parent?

2. Are you interested in including your child with special needs in your presentation? yes/no

3. Are you interested in including a sibling in your presentation? yes/no

4. Days of the week/times that you are most available to speak:

5. Best time of day/day of week to contact you?

6. What is your preferred method of communication? (check all that apply):

___ home phone
___ cell phone
___ e-mail
___ mail

7. Do you need an interpreter for your presentation? If yes, please specify:

8. Have you as a parent participated in any parent leadership or training programs? (e.g. PALs, PIP, DAWN, FACETS, People Can't Wait, community support groups, etc.):

9. What types of presentations are you interested in (check one or both)?:

___ pre-professional training (univ./college classrooms)
___ professional development

10. What large formats are you interested in (check all that apply)?:

___ large group lecture (more than 25)
___ small group lecture (less than 25)
___ panels
___ mentoring (working one-on-one)

11. Are you interested in being involved in other service activities?:

___ committees
___ advisory boards

12. Indicate which topics you would be interested in presenting on:

___ Your Family Story
___ Community Resources
___ Transition (at 3yrs.)
___ Health Care
___ IEP/IFSP/Education
___ Legislation
___ Peer Relationships
___ Augmentative Communication/Adaptive Equipment
___ Birth to 3
___ Therapy
___ Transition (at 18 yrs.)
___ Advocacy
___ Inclusion
___ Stress
___ Family Supports
___ Other: ________________________

Please take a moment to reflect on the following question:

Give an example of a message or idea you would like people to gain from your presentation.