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Number of Attendees / Número de Asistentes: First Name / Nombre: Last Name / Apellido: Email / Correo electrónico: Address / Dirección: City / Ciudad: State / Estado: 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 / Código postal: - Zip Suffix County / Condado: Phone / Teléfono: Phone Type | Tipo de Teléfono Home Mobile Other Work Primary Role | Rol primario Parent/Primary Caregiver -- Padre/Madre/Cuidador primario Other Family Member -- Otro Miembro de la Familia Resource or DD Foster Parent (Foster Parent) -- Padre/Madre de recursos (padre/madre de crianza) Individual w/Disability -- Persona con Discapacidad Adult Service Provider -- Proveedor de Servicios Adulto CASA-Court Appointed Special Advocate Community Partner - Disability Community Partner - General Community Partner - Public Policy/Advocacy Community Partner - Under-resourced/Underserved DD Foster Care Provider | Proveedor/a de DD Foster Care 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 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 youth with a disability Community Partner I/DD Professional Primary Language / Idioma Primario English Spanish -- Español 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 -- Otro Prefer Not to Answer -- Prefiero no contestar Ethnic and/or Racial Identity -- Identidad étnica y/o racial American Indian / Alaskan Native -- Indígena Norteamericana/Nativa de Alaska Asian/Asian-American -- Asiática Black/African American -- Negra/Afroamericana Black/African-American (Hispanic/Latino) -- Negra/Afroamericana (Hispana/Latino/a/x) Hawaiian/Pacific Islander -- Hawaiana/Isleña del Pacífico Hispanic/Latino/a/x -- Hispana/ Latino/a/x Multiracial -- Multirracial Multiracial (Hispanic/Latino/a/x) -- Multirracial (Hispana/ Latino/a/x) Russian/East European -- Rusia/Europea del Este White/Caucasian -- Blanca/Caucásica White (Hispanic/Latino/a/x) -- Blanca (Hispana/ Latino/a/x) Other -- Otra Prefer Not to Answer -- Prefiero no contestar School District / Distrito escolar Home School -- Estudiar en Casa None - Not in school -- Ningún- No asiste escuela 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 -- Otro Prefer Not to Answer -- Prefiero no contestar Medford Not in school Prefer Not to Answer� Gervais McMinnville My Household Experiences or Receives | Mi hogar experimenta o recibe Do you have a disability? | ¿Tiene una discapacidad? No Yes -- Si Prefer Not to Answer -- Prefiero no contestar Does anyone in your family use Oregon Health Plan (including DD Services/CHIP)? | ¿Alguien en su familia utiliza el Plan de Salud de Oregón (incluyendo los servicios para discapacitados/DD o CHIP)? Yes No Prefer Not to Answer 1st Child's Birthdate -- Fecha de Nacimiento del 1er niña/o 1st Child's Disability/Diagnosis -- Diagnóstico/discapacidad del 1er niña/o ADD/ADHD -- Deficit Atencional/Defict Atencional con Hiperatividad Autism Spectrum Disorders -- Desorden del Espectro Autista Autism/Down syndrome -- Autismo/Sindrome de Down Autism/Emotional - Behavioral Disabilities -- Autismo/Discapacidades Emocionales y del Comportamiento Autism/Intellectual Disability -- Autismo/Discapacidad Intelectual Blind/Visual Disability -- Ceguera/Impedimento Visual Cerebral Palsy -- Parálisis Cerebral Cerebral Palsy/Autism -- Parálisis Cerebral/Autismo Cerebral Palsy/Intellectual Disability -- Cerebral Palsy/Discapacidad Intelectual Communication Disorders -- Desordenes de Comunicación Deaf or Hearing Disability -- Sordera o Impedimento Auditivo Deafblindness -- Sordera Ceguera Developmental Disability -- Discapacidades del Desarrollo Down syndrome -- Sindrome de Down Dyslexia -- Dislexia Emotional - Behavioral Disabilities -- Discapacidades Emocionales y del Comportamiento Fetal Alcohol Syndrome/Effects -- Síndrome de Alcoholismo Fetal Fragile X Syndrome -- Sindrome X frágil Intellectual Disability -- Discapacidad Intelectual Intellectual Disability/Emotional - Behavioral Disabilities -- Discapacidad Intelectual/Discapacidades Emocionales y del Comportamiento Learning Disabilities -- Discapacidades del Aprendizaje Medical Conditions/Special Health Needs -- Condiciones Médicas/Necesidades Especiales de Salud Mental Health Conditions -- Condiciones de Salud Mental Multiple Disabilities -- Múltiples Discapacidades Physical Disability -- Discapacidades Físicas Post Traumatic Stress Disorder -- Trastorno de Estrés Postraumático Rare Disorders -- Desordenes Raros Rett Syndrome -- Síndrome de Rett Seizure Disorder/Epilepsy -- Trastorno Convulsivo/Epilepsia Sensory Processing Disorder -- Dificultades del Procesamiento Sensorial Tourette Syndrome -- Síndrome de Tourette Traumatic Brain Injury -- Traumatismo Craneoencefálico Twice Exceptional -- Superdotado(a) None -- Nada Unknown -- Desconocido Prefer Not to Answer -- Prefiero no contestar Post Traumatic Stress Disorder� 1st Child's Special Education Eligibility -- Elegibilidad para educación especial del 1.er niña/o Autism Spectrum Disorder -- Trastorno del Espectro Autista Deafblindness -- Sordera Ceguera Deafness or Hard of Hearing -- Sordos o con Problemas de Audición Developmental Delay -- Retraso del Desarrollo (9 Años) Emotional Behavior Disability -- Discapacidad Emocional Intellectual Disability -- Discapacidad Intelectual Orthopedic Impairment -- Discapacidad Ortopédico Other Health Impairment (OHI) -- Otros Discapacidad Médicos Specific Learning Disability -- Dificultad de Aprendizaje Específica Speech or Language Impairment -- Trastorno de Comunicación Traumatic Brain Injury -- Lesión Cerebral Traumática Visual Impairment -- Discapacidad Visual Currently Being Evaluated -- Actualmente Evaluando Unknown -- Desconocido None -- Nada Prefer Not to Answer -- Prefiero no contestar Autism Spectrum Disorder Autism Spectrum Disorder​ Developmental Delay​ Orthopedic Impairment Other Health Impairment (OHI)​ Specific Learning Disability​ Unknown​ 2nd Child's Birthdate -- Fecha de Nacimiento del 2do niña/o 2nd Child's Disability/Diagnosis -- Diagnóstico/discapacidad del 2do niña/o ADD/ADHD -- Déficit Atencional/ Défict Atencional con Hiperatividad Autism Spectrum Disorders -- Desorden del Espectro Autista Autism/Down syndrome -- Autismo/Sindrome de Down Autism/Emotional - Behavioral Disabilities -- Autismo/Discapacidades Emocionales y del Comportamiento Autism/Intellectual Disability -- Autismo/Discapacidad Intelectual Blind/Visual Disability -- Ceguera/Impedimento Visual Cerebral Palsy -- Parálisis Cerebral Cerebral Palsy/Autism -- Parálisis Cerebral/Autismo Cerebral Palsy/Intellectual Disability -- Cerebral Palsy/Discapacidad Intelectual Communcation Disorders -- Desordenes de Comunicación Deaf or Hearing Disability -- Sordera o Impedimento Auditivo Deafblindness -- Sordera-Ceguera Developmental Disability -- Discapacidades del Desarrollo Down syndrome -- Sindrome de Down Dyslexia -- Dislexia Emotional - Behavioral Disabilities -- Discapacidades Emocionales y del Comportamiento Fetal Alcohol Syndrome/Effects -- Síndrome de Alcoholismo Fetal Fragile X Syndrome -- Sindrome X frágil Intellectual Disability -- Discapacidad Intelectual Intellectual Disability/Emotional - Behavioral Disabilities -- Discapacidad Intelectual/Discapacidades Emocionales y del Comportamiento Learning Disabilities -- Discapacidades del Aprendizaje Medical Conditions/Special Health Needs -- Condiciones Médicas/Necesidades Especiales de Salud Mental Health Conditions -- Condiciones de Salud Mental Multiple Disabilities -- Múltiples Discapacidades Physical Disability -- Discapacidades Físicas Post Traumatic Stress Disorder -- Trastorno de Estrés Postraumático Rare Disorders -- Desordenes Raros Rett Syndrome -- Síndrome de Rett Seizure Disorder/Epilepsy -- Trastorno Convulsivo/Epilepsia Sensory Processing Disorder -- Dificultades del Procesamiento Sensorial Tourette Syndrome -- Síndrome de Tourette Traumatic Brain Injury -- Traumatismo Craneoencefálico Twice exceptional | Superdotado(a) None -- Nada Unknown -- Desconocido Prefer Not to Answer -- Prefiero no contestar 2nd Child's Special Education Eligibility -- Elegibilidad para educación especial del 2do niña/o Autism Spectrum Disorder -- Trastorno del Espectro Autista Deafblindness -- Sordera-Ceguera Deafness or Hard of Hearing -- Sordos o con Problemas de Audición​ Developmental Delay -- Retraso del Desarrollo (9 Años) Emotional Behavior Disability -- Discapacidad Emocional del Comportamiento Intellectual Disability -- Discapacidad Intelectual Orthopedic Impairment -- Discapacidad Ortopédico​ Other Health Impairment (OHI) -- Otros Discapacidad Médicos​ Specific Learning Disability -- Dificultad de Aprendizaje Específica​ Speech or Language Impairment -- Trastorno de Comunicación​ Traumatic Brain Injury -- Lesión Cerebral Traumática​ Visual Impairment -- Discapacidad Visual​ Currently Being Evaluated -- Actualmente Evaluando Unknown -- Desconocido None -- Nada Prefer Not to Answer -- Prefiero no contestar 3rd Child's Birthdate -- Fecha de Nacimiento del 3do niña/o 3rd Child's Disability/Diagnosis -- Diagnóstico/discapacidad del 3do niña/o ADD/ADHD -- Déficit Atencional/ Défict Atencional con Hiperatividad Autism Spectrum Disorders -- Desorden del Espectro Autista Autism/Down syndrome -- Autismo/Sindrome de Down Autism/Emotional - Behavioral Disabilities -- Autismo/Discapacidades Emocionales y del Comportamiento Autism/Intellectual Disability -- Autismo/Discapacidad Intelectual Blind/Visual Disability -- Ceguera/Impedimento Visual Cerebral Palsy -- Parálisis Cerebral Cerebral Palsy/Autism -- Parálisis Cerebral/Autismo Cerebral Palsy/Intellectual Disability -- Cerebral Palsy/Discapacidad Intelectual Communcation Disorders -- Desordenes de Comunicación Deaf or Hearing Disability -- Sordera o Impedimento Auditivo Deafblindness -- Sordera Ceguera Developmental Disability -- Discapacidades del Desarrollo Down syndrome -- Sindrome de Down Dyslexia -- Dislexia Emotional - Behavioral Disabilities -- Discapacidades Emocionales y del Comportamiento Fetal Alcohol Syndrome/Effects -- Síndrome de Alcoholismo Fetal Fragile X Syndrome -- Sindrome X frágil Intellectual Disability -- Discapacidad Intelectual Intellectual Disability/Emotional - Behavioral Disabilities -- Discapacidad Intelectual/Discapacidades Emocionales y del Comportamiento Learning Disabilities -- Discapacidades del Aprendizaje Medical Conditions/Special Health Needs -- Condiciones Médicas/Necesidades Especiales de Salud Mental Health Conditions -- Condiciones de Salud Mental Multiple Disabilities -- Múltiples Discapacidades Physical Disability -- Discapacidades Físicas Post Traumatic Stress Disorder -- Trastorno de Estrés Postraumático Rare Disorders -- Desordenes Raros Rett Syndrome -- Síndrome de Rett Seizure Disorder/Epilepsy -- Trastorno Convulsivo/Epilepsia Sensory Processing Disorder -- Dificultades del Procesamiento Sensorial Tourette Syndrome -- Síndrome de Tourette Traumatic Brain Injury -- Traumatismo Craneoencefálico Twice Exceptional | Superdotado(a) None -- Nada Unknown -- Desconocido Prefer Not to Answer -- Prefiero no contestar 3rd Child's Special Education Eligibility -- Elegibilidad para educación especial del 3do niña/o Autism Spectrum Disorder -- Trastorno del Espectro Autista Deafblindness -- Sordera Ceguera Deafness or Hard of Hearing -- Sordos o con Problemas de Audición​ Developmental Delay -- Retraso del Desarrollo (9 Años) Emotional Behavior Disability -- Discapacidad Emocional del Comportamiento Intellectual Disability -- Discapacidad Intelectual Orthopedic Impairment -- Discapacidad Ortopédico​ Other Health Impairment (OHI) -- Otros Discapacidad Médicos​ Specific Learning Disability -- Dificultad de Aprendizaje Específica​ Speech or Language Impairment -- Trastorno de Comunicación​ Traumatic Brain Injury -- Lesión Cerebral Traumática​ Visual Impairment -- Discapacidad Visual​ Currently Being Evaluated -- Actualmente Evaluando Unknown -- Desconocido None -- Nada Prefer Not to Answer -- Prefiero no contestar If you have a coupon, please enter code here (case-sensitive):