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Arc of Onondaga Parent Advocacy CONTACT FORM

Information submitted on this form is confidential and is protected by federal HIPAA laws. The Parent Advocacy program is a free resource.


Parent/Guardian Professional (Title &/or Agency)

Name: *	A Name is required.
Phone: *	A phone number is required.Invalid format. (ex. (123) 456-7890)
Alternate Phone:
Email: *	An Email is required.Invalid format.

Address:

City: *	A City is required.
State: *	A State is required.	Zip: *	A Zip Code is required.Invalid format.
County: *	A County is required.
School District: *	A School District is required.
Building:

Ethnicity:	Please select an item.

Child/Student’s Name: *	A Child/Student's Name is required.
Age: *	An Age is required.
DOB: *	A Date of Birth is required.

Child's Ethnicity:	Please select an item.
Disability/Classification on IEP: *	A value is required.
Other Disability or suspected disability:

How did you hear about our program? Check all that apply	Previous Contact Other Parent Professional Media Phone Book Arc Website		Other Website Search Engine Agency Literature Service Provider Presentation Other

Reason for Contact: Check all that apply	Abuse/ Neglect/ Exploitation Education/ Advocacy Medicare/ Medicaid ADA (American’s with Disability Act) Disability Information on Medical/Therapeutic Agency Information Financial (SSI/SSD) Support Assistive Technology		Guardianship Transportation Day Programs Housing/ Residential Vocational Legal/ Advocacy 504 plan CSE meeting Transition Other

Preferred method of contact:	Phone (best time to call) Email Please mail me information on

Is there anything else you would like us to know to better serve you?