Parent Exchange Registration

*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.

(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.