Parent Exchange Registration

PARENT EXCHANGE REGISTRATION FORM
At this time, this form can only be used if you use EXPLORER. If you are not, or are having difficulty with this form, please use this email link and provide as much information from this form as possible in the email: Parent Exchange By using this email link, you are giving SHARE Network permission to release your my NAME, PHONE NUMBER, and EMAIL ADDRESS to connect to another parent in our database requesting a parent exchange.

(*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
Son/Daughter's insurance Private Insurance
Medicaid Fee for Service Yes No If HMO, which one?
Medicaid Waiver
Disability and/or family support organizations you are connected with
Family income per year
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.

(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

(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.