PARENT EXCHANGE REGISTRATION FORM
(*Required Fields)

PARENT INFORMATION

*First Name     *Last Name  

Address    *City  
*State/Prov   Country  
*Contact persons name 
*Email address      
*Home Phone   Area Code     
Cell Phone   Area Code     
Work Phone   Area Code      Ext:  
How did you hear about us?
Relationship Status
Disability and/or family support organizations you are connected with

DIAGNOSIS INFORMATION ON SON/DAUGHTER

(NOTE: If you have more than one child with a diagnosis, please fill out this form and submit for each child.  You need only enter your first and last name in the section above for each additional child.)
*Name
*Date of Birth
Sex Male Female
*Diagnosis/Disability
Time of diagnosis Before birth At birth     At age of
My son/daughter's disability/special health care need has given me experiences related to the following
(Please check all that apply)

Speech
Vision
Hearing
Mobility
Behavior
Toileting
Spine
Feeding
Fluids
Diet
Personal Attendant Services
Adult Care
Lifts
Equipment

Employment
School Programs
Housing
SSI
IEP
ISPP
Guardianship
Transportation
Travel
DTT/Afterschool Programs
Grants
Insurance(s)
Voucher System
Respite
 
Therapies
          OT
          PT
          Habilitation
            
Speech Therapy
            
Vision Therapy
          Cognitive
            
Play
            
Psychotherapy
          Nutritional
            
Water Play
          Switch Toys
            
Sensory Room
      
              Other
Special equipment, medical procedures and/or treatments

(YES must be checked in order to participate in the Parent Exchange)

SHARE Network has my permission to release only my NAME, PHONE NUMBER, and EMAIL ADDRESS using the information provided to the SHARE Network to connect to another parent in our database requesting a parent exchange.

* Yes

As with all information received by the SHARE Network and as outlined in our Privacy Policy, no information will EVER be sold or given away, and will only be SHARE'd with those giving permission through the use of this form for the Parent Exchange as indicated above.
 

  

 


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