12th Annual Traveling Mini Conference 2019

Parent Leadership & Advocacy Conference 2019

12th Annual Traveling Mini-Conference for parents, professionals and community members; serving infants, children and youth at risk of, or with disabilities.

Question Title

* 1. What island are you registering for? (Parents, Professionals and Community Members)

Lanai; Thursday, August 22, 2019; 2:00-4:00 pm @ Lanai High & Elementary School

Molokai; Thursday, August 8, 2019; 3:00 - 7:00 pm @ Home Pumehana

Hilo; Saturday, September 7, 2019; 10:00 am - 2:00 pm @ Imiloa Astronomy Center

Maui; Thursday, September 12, 2019; 4:30 - 9:00 pm @ UH Maui College Class Ac Restaurant

Oahu 1: Saturday, September 21, 2019; 8:00 am - 2:00 pm @ BYUH - Laie

Kauai; Saturday, September 28, 2019; 9:00 am - 2:30 pm @ Lihue Library

Oahu 2; Saturday, October 5, 2019; 8:30 am - 2:00 pm TBD

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* 2. Please complete the following: Parents/Professionals/Community Members

Name

Company

Address

Address 2

City/Town

State

ZIP

Country

Email Address

Phone Number

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* 3. Please select your role as a conference participant. I am a . . .

Parent/Guardian of a child with a disability

Parent/Guardian

Surrogate Parent

Professional (Skip to question 9 and 10)

Grandparent/Family Member of a child with a disability

Student (Skip to question 9 and 10)

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* 4. If you are a parent of a child with a disability, please answer questions 4-8. All others please skip to question 9 & 10.
Choose the appropriate box below that represents your child with a disability

	Male	Female
Age 0-2	Age 0-2 Male	Age 0-2 Female
Age 3-5	Age 3-5 Male	Age 3-5 Female
Age 6-8	Age 6-8 Male	Age 6-8 Female
Age 9-12	Age 9-12 Male	Age 9-12 Female
Age 13-15	Age 13-15 Male	Age 13-15 Female
Age 16-18	Age 16-18 Male	Age 16-18 Female
Age 19 and above	Age 19 and above Male	Age 19 and above Female

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* 5. Please describe your child's race/ethnicity. (Parents Only)

African American

Asian

Caucasian

Filipino

Hispanic

Hawaiian/Part Hawaiian

Pacific Islander

Other (specify)

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* 6. Please describe your child's disability.

Deaf-Hearing Disability

Developmental delay

Emotional Disability

Intellectual Disability

Multiple Disability

Orthodpedic Disability

Other Health Disability

Specific Learning Disability

Speech Language Disability

Traumatic Brain Injury

Visual Impairment including Blindness

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* 7. Will you be attending our conference with your children? (Parents Only)

Yes

If yes, please provide the name of your child(ren) and their ages in the box below.

Other (please specify)

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* 8. Are you or your spouse an active duty service member? (Parents only)

Yes

If yes, which Branch

Other (please specify)

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* 9. As a professional/community member, I am attending the conference in which capacity? Please select the best option.

Administrator/Manager

Teacher/Tutor

Vendor-Exhibitor

Provider- i.e., early childhood, behavior health, Part B - IDEA, Attorney, Doctor

Community Member-i.e., friends of the disability community

Student

Other (please specify below)

Other (please specify)

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* 10. Is this your first time attending our conference? (Parents, Professionals/Community Members)

Yes

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* 1. What island are you registering for? (Parents, Professionals and Community Members)

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* 2. Please complete the following: Parents/Professionals/Community Members

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* 3. Please select your role as a conference participant. I am a . . .

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* 4. If you are a parent of a child with a disability, please answer questions 4-8. All others please skip to question 9 & 10.Choose the appropriate box below that represents your child with a disability

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* 5. Please describe your child's race/ethnicity. (Parents Only)

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* 6. Please describe your child's disability.

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* 7. Will you be attending our conference with your children? (Parents Only)

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* 8. Are you or your spouse an active duty service member? (Parents only)

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* 9. As a professional/community member, I am attending the conference in which capacity? Please select the best option.

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* 10. Is this your first time attending our conference? (Parents, Professionals/Community Members)

* 4. If you are a parent of a child with a disability, please answer questions 4-8. All others please skip to question 9 & 10.
Choose the appropriate box below that represents your child with a disability