The Breathe Awareness Campaign
Matching Families with Special Needs to community organizations & individuals to raise awareness to the joy and the pain experienced by special needs families. All information will be kept confidential and will only be shared with your permission.
Person completing form Name
First Name
Last Name
How are you related to Individual with special needs
Parent/Guardian
Relative
Friend
Direct Support Professional
Teacher
Other
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Individual's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Diagnosis
Individual Lives with:
Parent/Guardian
Relative
Friend
Alone
Host Home
Agency Home
Other
Does Individual receive medicaid services?
Yes
No
Does Individual have a NOW/Comp Waiver
Yes
No
Please select all that apply to individual
attends school
attends day program
works
Please share any information you would like for the organization your family is matched with to know.
Is there anything specific that would help your family? If so, please explain.
If you could change one thing about your family circumstances, what would you change?
Does individual attend a local church? If so, what is the name of the church?
Do you feel supported by your community
Yes
No
If yes, how?
What is one thing you would like for the world to know about families with special needs?
Do you give us permission to share your information with the organization or individual you are matched with? If you select no, a Breathe Team member will be the liaison between your family & the community sponsor.
Yes, you may share my information
No, please do not share my information
Submit
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