Registration Form

Number of Attendees: First Name: Last Name: Email: Phone: Phone Type: Home Mobile Other Work Address: Address Line 2 City: County (Not Country): State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Company/Organization: Primary Role (Parent, Educator, etc.) Parent/Primary Caregiver Other Family Member Resource or DD Foster Parent (Foster Parent) Individual w/Disability CASA Community Partner Early Childhood: EI/ECSE Early Childhood: Provider/Staff Educator: General K-12 Educator: Higher Education Educator: Special K-12 Educator: Transition Services (18-21) I/DD Professional Medical/Therapy Provider Provider State Agency Staff Tribal Partner Voc Rehab Admin/Staff Other Secondary Role Parent/Primary Caregiver Other Family Member Resource Parent (Foster Parent) Individual with a Disability Adult Service Provider CASA-Court Appointed Special Advocate Community Partner - Disability Community Partner - General Community Partner - Public Policy/Advocacy Community Partner - Underserved DD Services - Brokerage Admin/Staff DD Services - CDDP Admin/Staff DD Services - DSP/PSW DD Services - ODDS Admin/Staff Early Learning and Care Provider/ Staff EI/ECSE Provider/ Staff ESD Admin/Educator/Staff Foster Care Provider Higher Education Admin/Educator/Student K-12 General Education - Admin/Educator/Staff K-12 Special Education - Admin/Educator/Staff Local Gov Agency Staff Medical Provider/Staff Mental/Behavioral Health Provider/Staff OT/PT/SLP Therapy Provider/Staff State Agency - Admin/Staff State Agency Staff - ODE State Agency Staff - Other Transition Services - Admin/Educator/Staff Tribal Partner Voc Rehab Admin/Staff Other -- Otro Ethnic and/or Racial Identity American Indian / Alaskan Native Asian/Asian-American Black/African American Black/African-American (Hispanic/Latino) Hawaiian/Pacific Islander Hispanic/Latino/a/x Multiracial Multiracial (Hispanic/Latino/a/x) Russian/Eastern European White/Caucasian White (Hispanic/Latino/a/x) Other Prefer Not to Answer Primary Language English Spanish American Sign Language (ASL) Arabic Chinese-Cantonese Chinese-Mandarin Duala Fanti French Hindi Japanese Korean Marshallese Romanian Russian Serbo-Croatian/Bosnian Somali Tagalog Ukrainian Vietnamese Other Prefer Not to Answer Secondary Language (If Applicable) None English Spanish American Sign Language (ASL) Arabic Chinese-Cantonese Chinese-Mandarin Duala Fanti French Hindi Japanese Korean Marshallese Romanian Russian Serbo-Croatian/Bosnian Somali Tagalog Ukrainian Vietnamese Other Prefer Not to Answer Disability Status No Yes Prefer Not to Answer School District: Home School None - Not in school Adel Adrian Alsea Amity Annex Arlington Arock Ashland Ashwood Astoria Athena-Weston Baker Bandon Banks Beaverton Bend-La Pine Bethel Blachly Black Butte Brookings-Harbor Burnt River Butte Falls Camas Valley Canby Cascade Centennial Central Central Curry Central Linn Central Point Chemawa Indian SD Clackamas ESD Clatskanie Colton Condon Coos Bay Coquille Corbett Corvallis Cove Creswell Crook County Crow-Applegate Culver Dallas David Douglas Days Creek Dayton Dayville Diamond Double O Douglas County SD 15 Douglas County SD 4 Drewsey Dufur Public Schools Eagle Point Echo Elgin Elkton Enterprise Estacada Eugene Falls City Fern Ridge Forest Grove Fossil Frenchglen Gaston Gervais Gladstone Glendale Glide Grants Pass Greater Albany Gresham-Barlow Harney County Harney County SD 3 Harney County SD 4 Harney County Union High SD 1j Harper Harrisburg Helix Hermiston Hillsboro Hood River County Huntington Imbler Ione Jefferson 14J (Marion Co) Jefferson County 509J (Jefferson Co) Jewell John Day Jordan Valley Joseph Junction City Juntura Klamath County Klamath Falls City Schools Knappa La Grande Lake County Lake Oswego Lebanon Community Schools Lincoln County Schools Long Creek Lowell Malheur County Mapleton Marcola McKenzie McMinnville Medford Milton-Freewater Mitchell Molalla River Monroe Monument Morrow Mt Angel Multnomah ESD Myrtle Point Nampa Neah-Kah-Nie Nestucca Valley Newberg North Bend North Clackamas North Douglas North Lake North Marion North Powder North Santiam North Wasco County Nyssa Oakland Oakridge Ontario Oregon City Oregon Connections Academy - Santiam Canyon SD Oregon Trail Paisley Parkrose Pendleton Perrydale Philomath Phoenix-Talent Pilot Rock Pine Creek Pine Eagle Pinehurst Pleasant Hill Plush Port Orford-Langlois Portland Powers Prairie City Prospect Rainier Redmond Reedsport Reynolds Riddle Riverdale Rogue River Roseburg Salem-Keizer Santiam Canyon Scappoose Scio Seaside Sheridan Sherman Sherwood Silver Falls Sisters Siuslaw South Harney South Lane South Umpqua South Wasco County Spray Springfield St Helens St Paul Stanfield Suntex Sutherlin Sweet Home Three Rivers/Josephine CU Tigard-Tualatin Tillamook Troy Ukiah Umatilla Union Union-Baker ESD Vale Vernonia Wallowa Warrenton-Hammond West Linn-Wilsonville Willamina Winston-Dillard Woodburn Yamhill-Carlton Yoncalla Other Prefer Not to Answer Medford Not in school Prefer Not to Answer Gervais McMinnville Gladstone 1st Child's Name: 1st Child's Birthdate: 1st Child's Primary Disabilities/Diagnosis: ADD/ADHD Autism Spectrum Disorders Autism/Down syndrome Autism/Emotional - Behavioral Disabilities Autism/Intellectual Disability Blind/Visual Disability Cerebral Palsy Cerebral Palsy/Autism Cerebral Palsy/Intellectual Disability Communication Disorders Deaf or Hearing Disability Deafblindness Developmental Disability Down syndrome Dyslexia Emotional - Behavioral Disabilities Fetal Alcohol Syndrome/Effects Fragile X Syndrome Intellectual Disability (IDD) Intellectual Disability/Emotional - Behavioral Disabilities Learning Disabilities Medical Conditions/Special Health Needs Mental Health Conditions Multiple Disabilities Physical Disability Post Traumatic Stress Disorder Rare Disorders Rett Syndrome Seizure Disorder/Epilepsy Sensory Processing Disorder Tourette Syndrome Traumatic Brain Injury Twice Exceptional None Unknown Prefer Not to Answer 1st Child's Primary Special Education Eligibility (Front Page of IEP): Autism Spectrum Disorder Deafblindness Deafness or Hard of Hearing Developmental Delay Emotional Behavior Disability Intellectual Disability Orthopedic Impairment Other Health Impairment Specific Learning Disability Speech or Language Impairment Traumatic Brain Injury Visual Impairment Currently Being Evaluated Unknown None Prefer Not to Answer 1st Child's Race and/or Ethnicity American Indian-Alaskan Native Asian/Asian-American Black/African American Black/African-American (Hispanic/Latino/a/x) Hawaiian/Pacific Islander Hispanic/Latino/a/x Multiracial Multiracial (Hispanic/Latino/a/x) Russian/Eastern European White/Caucasian White (Hispanic/Latino/a/x) Other Prefer Not to Answer 2nd Child's Name 2nd Child's Birthdate 2nd Child's Primary Disability Diagnosis ADD/ADHD Autism Spectrum Disorders Autism/Down syndrome Autism/Emotional - Behavioral Disabilities Autism/Intellectual Disability Blind/Visual Disability Cerebral Palsy Cerebral Palsy/Autism Cerebral Palsy/Intellectual Disability Communcation Disorders Deaf or Hearing Disability Deafblindness Developmental Disability Down syndrome Dyslexia Emotional - Behavioral Disabilities Fetal Alcohol Syndrome/Effects Fragile X Syndrome Intellectual Disability (IDD) Intellectual Disability/Emotional - Behavioral Disabilities Learning Disabilities Medical Conditions/Special Health Needs Mental Health Conditions Multiple Disabilities Physical Disability Post Traumatic Stress Disorder Rare Disorders Rett Syndrome Seizure Disorder/Epilepsy Sensory Processing Disorder Tourette Syndrome Traumatic Brain Injury Twice exceptiona None Unknown Prefer Not to Answer 2nd Child's Primary Special Education Eligibility Autism Spectrum Disorder Deafblindness Deafness or Hard of Hearing Developmental Delay Emotional Behavior Disability Intellectual Disability Orthopedic Impairment Other Health Impairment Specific Learning Disability Speech or Language Impairment Traumatic Brain Injury Visual Impairment Currently Being Evaluated Unknown None Prefer Not to Answer 2nd Child's Race and/or Ethnicity American Indian / Alaskan Native Asian/Asian-American Black/African American Black/African-American (Hispanic/Latino/a/x) Hawaiian-Pacific Islander Hispanic/Latino/a/x Multiracial Multiracial (Hispanic/Latino/a/x) Russian/Eastern European White/Caucasian White (Hispanic/Latino/a/x) Other Prefer Not to Answer 3rd Child's Name 3rd Child's Birthdate 3rd Child's Primary Disability Diagnosis ADD/ADHD Autism Spectrum Disorder Autism/Down syndrome - Autism/Emotional - Behavioral Disabilities Autism/Intellectual Disability Blind/Visual Disabilit Cerebral Palsy Cerebral Palsy/Autism Cerebral Palsy/Intellectual Disability Communcation Disorders Deaf or Hearing Disability Deafblindness Developmental Disability Down syndrome Dyslexia Emotional - Behavioral Disabilities Fetal Alcohol Syndrome/Effects Fragile X Syndrome Intellectual Disability (IDD) Intellectual Disability/Emotional - Behavioral Disabilities Learning Disabilities Medical Conditions/Special Health Needs Mental Health Conditions Multiple Disabilities Physical Disability Post Traumatic Stress Disorder Rare Disorders Rett Syndrome Seizure Disorder/Epilepsy Sensory Processing Disorder Tourette Syndrome Traumatic Brain Injury Twice Exceptional None Unknown Prefer Not to Answe 3rd Child's Primary Special Education Eligibility Autism Spectrum Disorder Deafblindness Deafness or Hard of Hearing Developmental Delay (to age 9) Emotional Behavior Disability Intellectual Disability Orthopedic Impairment Other Health Impairment Specific Learning Disabilit Speech or Language Impairment Traumatic Brain Injury Visual Impairment Currently Being Evaluated Unknown None Prefer Not to Answer 3rd Child's Racial and/or Ethnic Identity American Indian / Alaskan Native Asian/Asian-American Black/African American Black/African-American (Hispanic/Latino/a/x) Hawaiian/Pacific Islander Hispanic/Latino/a/x Multiracial Multiracial (Hispanic/Latino/a/x) Russian/Eastern European White/Caucasian White (Hispanic/Latino/a/x) Other Prefer Not to Answer If you have a coupon, please enter code here (case-sensitive): Relation of Registrant to Attendees:   Same Household Same Company