Date:

Martial Status: Married Single Divorced Widowed Separated

Other:

Name:

Address:

City: County:

State: Zip Code:

Phone: Home: Cell:

Work (if it is okay to receive calls there):

Email address:

Newsletter: How would you like to receive our newsletter? U.S. Mail Email YahooGroup

Would you like to join one of our Listservs? Local area Listserv Advocacy Listserv

ADD/ADHD Listserv Autism Listserv Bipolar Listserv Dad's Listserv ECI

Listserv Homeschooler Listserv Medical Home Listserv Preemie or NICU Listserv

Transition Listserv

Relationship with child with disability: Parents Mother Father Grandparent

Sibling Other:

Child's Disabilitiy Child's Age:

Family Ethnicity: Multiracial African-American Asian-American Caucasian

Hispanic Native American Other:

What do you want from a match with another parent:

INFORMATION ON INDIVIDUAL WITH SPECIAL NEED:

Name:

Date of Birth: Age:

Gender: Female Male

Child Ethnicity: Multiracial African-American Asian-American Caucasian

Hispanic Native American Other:

Please list all diagnosis/symptoms/etc.:

For us to make the best match possible, please indicate the level of function in each of the following catergories. For example, under cognitive, you might list "typical", "mild mental retardation", or "unknown".

Cognitive:

Mobility:

Behavior:

Speech/Communication:

Vision:

Hearing:

Toileting skills:

Eating skills:

Special equipment:

Other comments:

School program and school district OR daytime activities:

Siblings:

Name: Date of Birth:

Any special needs:

Name: Date of Birth:

Any special needs:

Name: Date of Birth:

Any special needs:

Name: Date of Birth:

Any special needs:

Where did you hear about Texas Parent to Parent? ECI Program School Agency

Phone Book Another parent Parent Group TxP2P flier or newsletter Internet

Other:

Please tell us how you heard about TxP2P: Another Parent A Parent from South Texas Team - Parent's Name Parent from DFW Team - Parent's Name Agency or Program ECI or DSHS Internet Phone Book

Other: