Parent Consultant Directory Consent Form

Thank you for agreeing to participate in the directory. Please fill out this consent form as completely as possible and return by February 27, 2004. Because this involves your signature, we need a "hard" copy of this so please mail it or fax it back to us.

Parent Name(s):


Home Address:


City:


County:


Zip Code:


Phone Numbers:
Home:


Work:


Cell:


E-Mail Address(es):


Fax (if available):


Please indicate your consent for the following:

• _____ I give my permission to include the information provided on the Biographical Form in the Parent Consultant Directory, a project funded by the Wisconsin Department of Public Instruction's State Improvement Grant and the Waisman Center University Center for Excellence in Developmental Disabilities for the years 2004-2007.
• _____ I would like to be included in the Waisman Center's Family Action Network mailing list to receive valuable information for families with children with special needs.