Parent
Consultant Directory
Please complete this form by Friday, February 27, 2004.
There will two ways to submit
this form
1. Family
Biographical Information in PDF format
a. click here for PDF Format
- (HTML version)
b. print and answer questions
c. send by mail to:
Lynn Havemann
1500 Highland Avenue Rm. A105
Madison, WI 53705
or
2. Family
Biographical Information or send electronically
a. fill in blanks
b. press the Apply Now button at the bottom of
form. Your completed work will be sent to Lynn Havemann. If youve
received a hard copy of this form, feel free to mail it back using
the address on the consent form.
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Family Biographical Information
- Parents Name(s):
| Children/Youth Names: | Yr. of Birth: |
Children(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?
No
Yes
3. Are
you interested in including a sibling in your presentation?
No
Yes
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 (community settings)
10.
What formats are you interested in (check all that apply)?
large group lecture (more than 25)
panels
small group lecture (less than 25)
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 | Birth to 3 |
| Community Resources | Therapy |
| Transition (at 3yrs.) | Transition (at 18 yrs.) |
| Health Care | Advocacy |
| IEP/IFSP/Education | Inclusion |
| Legislation | Stress |
| Peer Relationships | Family Supports |
| Augmentative Communication/Adaptive Equipment | |
| 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.