Parents of children with developmental disabilities and special health needs
Registration Form
Fill out form below for starting Monday January 22. Every Monday for 8 weeks. Ends March 11th.
Which group will you be signing up for?
10am-11am (in person)
6pm-7pm (telehealth)
Name of Parent #1
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Male | Female
Male
Female
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Will another parent be joining you? If yes, please fill out information below. If not, please skip to age(s) of your child.
Yes
No
Name of Parent #2
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Male | Female
Male
Yes
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Child's Name
First Name
Last Name
Child's DOB
-
Month
-
Day
Year
Date
Please tell us about your child's special needs.
*
Are you or your child(ren) currently a client of WSCC?
*
Yes
No
Insurance?
Private
Medicaid
None
None, but interested in sliding scale program
If you have insurance, please provide carrier name, group and/or ID number
How did you hear about this group?
*
Social Media (Facebook, Instagram, LinkedIn, Twitter)
Enewsletter/Eblast from WSCC
Word of Mouth
Online Ad
WSSC Counselor
Other
Questions/Comments
Submit
Should be Empty: