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Regional Parent Resource (RPR) Application

Date of Application:

County:

Name:

Address:

City:

State:

Zip Code:

Home Phone: (include area code) enter as xxx-xxx-xxxx

Work Phone: (include area code) enter as xxx-xxx-xxxx

Cell Phone: (include area code) enter as xxx-xxx-xxxx


Alternate Email Address:


What is the best time to reach you?  (Please indicate a time between 8:00 a.m. and 4:00 p.m., Monday through Friday)


Please check:
African American
Asian
Caucasian
Hispanic
Native American
Other Nationality

Language(s): (check all that apply)
English
Spanish
Other

Number of Children:


Age(s):


Any children with disabilities/suspected disabilities?
Yes                  No

Describe disabilities: (check primary disability)
ADD/ADHD
Autistic
Deaf/Blind
Emotional Disability
Hearing Impaired
Learning Disabled
Mental Retardation
Multiply Disabled
Neurologically Impaired
Other Health Impaired
Physically Disabled
Speech/Language Disorder
Suspected (Undiagnosed)
Traumatic Brain Injury (TBI)
Visually Impaired

Does your child receive special education services?
Yes    If yes, please indicate your child's school district or corporation 
No

Have you ever attended a workshop conducted by INSOURCE?
Yes                   No

Have you been involved in the early intervention or special education process for your child?
Yes                   No

Are you involved in any parent groups in your area?
Yes                   No

Are you active in other organizations?
Yes        If yes, please indicate what organization(s):             No

To what extent are you willing to do the following activities in the future.  (Please indicate your willingness by selecting a number from 4 to 0 with 4 being the most willing and 0 being the least willing.)

Personal Advocacy:
Learn more about resources and services available

4

3

2

1

0

           
Participate in meetings

4

3

2

1

0

Raise issues related to special education on a local level

4

3

2

1

0

           

Work with Other Parents
Share information with parents

4

3

2

1

0

Advise and problem-solve

4

3

2

1

0

Accompany parents to meetings and case conferences

4

3

2

1

0

  Periodically report to INSOURCE on work with parents

4

3

2

1

0

Advocacy/Training Activities
Assist in organizing meetings or workshops

4

3

2

1

0

Assist in conducting training workshops

4

3

2

1

0

Work cooperatively with special education and/or school personnel

4

3

2

1

0

Participate in an annual meeting with other Regional Parent Resources

4

3

2

1

0

 Will you require any special accommodations?
Yes     If yes, please specify:
No

Additional comments: