FAMILY INFORMATION 

Parent's (or Caregiver's) Name
 

*In which county of New York State do you live: Select One Albany Allegany Bronx Broome Cattaraugus Cayuga Chautaugqua Chemung Chenango Clinton Columbia Cortland Delaware Dutchess Erie Essex Franklin Fulton Genessee Greene Hamilton Herkimer Jefferson Kings Lewis Livingston Madison Monroe Montgomery Nassau New York Niagara Oneida Onondaga Ontario Orange Orleans Oswego Otsego Putnam Queens Rennselaer Richmond Rockland St. Lawrence Saratoga Schenectady Schoharie Schuyler Seneca Steuben Suffolk Sullivan Tioga Tompkins Ulster Warren Washington Wayne Westchester Wyoming Yates

*First Name:  
*Last Name:

Relationship to person with special need:

Address:

City:    State: Zip:        

*Home Phone: ()     
Best Time to Reach Me at Home:

Is it OK for us to call you at work?  Yes      No

Work Phone: ()  
Best Time to Reach Me at Work:

Fax: ()  

*Email:

Race:   

Languages:
   

Person With Special Health Care Need or Disability

We will protect all information that is provided to Parent to Parent including names, addresses, phone numbers, birthdates and medical information.  For details see our Privacy Statement.

First Name:   
Last Name:

DOB: //  (mm/dd/yy)   

Sex: Male Female

When was disability diagnosed? 
Before Birth
After Birth
At the age of

List all disabilities or conditions

Other children names and ages

Please include any additional information about your child that might assist in making a good match, i.e., twins, disability the result of an accident, play/social skills, hobbies/interests, etc.  If you would like to speak to another parent about a specific topic related to your child, please indicate.

Please include any special issues or concerns you may have regarding your child.

I would like to be contacted by Parent to Parent of NYS to explain my request further.

Parent to Parent has my permission to release my name, phone number and/or Email address to a trained support parent in order to complete this request for a parent match.
yes
no