Parent Advocate Request

Parent Advocate Request

Please complete the following form to request more information about securing a parent advocate. Advocates are available to assist clients and their families as they learn the ins and outs of the often difficult and confusing Individualized Education Program process. The advocate ensures that parents and children receive fair treatment, and works with school staff to ensure that The Arc clients and their families understand the programs and resources that are available to them.
Name of Child*

First NameLast Name
Name of Child's School*
Does your child currently have an Individual Education Plan? *
What is your child's current grade level? *
Child's Date of Birth*

MonthDayYear
Date
Name of Parent/Legal Guardian *

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Tell us why you are requesting assistance. *
Date:   Date*
I,   First Name*   Last Name* , the undersigned legally responsible person for     First Name*   Last Name*    do hereby consent and grant permission to The Arc of Buncombe County to advocate on behalf of   Child's First Name*   Child's Last Name* to gather and exchange information with any individuals or professionals representing agencies, schools, and local and state facilities pertaining to the welfare of the client.

Parent’s/Guardian’s Full Name:   First Name*   Last Name*
Parent’s/Guardian's Mailing Address:   Street Address*   Address Line 2*   City*   State*   Zip*
Parent’s Phone Number (daytime):   Area Code*   Phone Number*
Signature of Parent/Guardian:   Signature*

Parent Advocate: Sarah Cain, sarah@arcofbc.org, 828-450-6476
Should be Empty: