| This service is
for parents who live in the Chicago area. Please
complete this form if you are interested in either
receiving telephone peer support or providing telephone peer
support to others. All information is kept confidential.
You may submit
this form via Email, or it can be printed and mailed to:
Answers for Special Kids
1029 Hinman.
Evanston, IL 60202 |
FAMILY INFORMATION |
|
Parent or Caregiver Name* |
First
Last
|
Are you interested in?* |
Receiving Telephone Peer Support
Providing Telephone Peer Support
Receiving and Providing Telephone Peer Support |
Address |
|
City |
|
State |
|
Zip |
|
Home Telephone* |
|
Best time to reach me at home |
|
Is it OK for us to call you at work? |
YES
NO |
Work Telephone |
|
Best time to reach me at work |
|
E-mail |
|
Your relationship to the child* |
Mother
Father
Other. Please explain:
|
Languages |
|
 |
CHILD WITH SPECIAL NEED |
|
Child's Name |
First
Last
|
Child's Date of Birth |
(mm/dd/yy) |
Sex |
Male
Female |
When was disability diagnosed? |
Before birth
After birth At the age of
|
List all disabilities or conditions |
|
Other children names and ages |
|
| Please include any additional information about your child that
might assist in making a good match, i.e., twins, disability the
result of an accident, play/social skills, hobbies/interests, etc. If
you would like to speak to another parent about a specific topic
related to your child, please indicate. |
|
Please include any special issues or concerns you may have regarding
your child: |
|
I would like to be contacted by Parent to Parent
of NYS to explain my request further. |
YES
NO |
A.S.K. Parent Matching has my permission to
release my name, phone number and/or Email address to
another parent asking for support |
YES
NO |
|
|
