Support Group Registration

Support Group for Parents of Black Children with Disabilities

Monthly

6:00-7:30pm

Online via Zoom

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* 1. Registration

First & Last Name *

Address *

Address 2

City *

State *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. Please indicate whether you are one of the following:

Parent/Guardian

Caregiver

Advocate/Professional

Other/Otro (please specify)

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* 3. Please describe your race/ethnicity.

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Two or more races

Decline to answer/Negarse a responder

Other/Otro (please specify)

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* 4. Please select your child's disabilities.

ADD/ADHD

Autism Spectrum Disorder

Deaf-Blindness

Developmental Delay

Emotional Disturbance

Gifted

Hearing Imp. (Including Deafness)

Intellectual Disability

Multiple Disablities

No IDEA Disability

Orthopedic Impairment (Physical)

Other Health Impairment

Specific Learning Disability

Speech Language Impairment

Suspected/Undiagnosed

Traumatic Brain Injury

Visual Impairment (including blindness)

Other (please specify)

Support Group Registration

Support Group for Parents of Black Children with Disabilities

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* 1. Registration

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* 2. Please indicate whether you are one of the following:

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* 3. Please describe your race/ethnicity.

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* 4. Please select your child's disabilities.

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* 5. What is your child/children's age(s)?

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* 6. What are you hoping to get out of this support group?

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* 7. Do you require any accommodations? If so, please specify.

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* 8. How did you hear about Show and Tell?