Partners™ for Youth with Disabilities

Mentoring programs that assist young people to reach their full potential





Home	About Us	Programs	How to Help	National Center

Parents Group Application

This application is for parents interested in joining any of our parent groups.

You have options for completing this application:

Apply online below and submit answers through this accessible website
Or, download one of these files: .pdf file, .doc file, complete and mail to the address included.

This application may take 10-20 minutes to complete. Please, review the entire page before you start. Need help? Email: info@pyd.org

Applied Previously?
If you have applied previously to PYD in the last six months you do not have to apply again. Simply, complete the short program/group reapply page.

Required information is indicated with an *asterisk.

Start by Choosing the Programs You Are Interested in (ALT+S):
*Select a program (choose ALL that apply):		Program Option: Parents Chat Online Group (POL) Greater Boston Region Parent Group Greater Springfield Region Parent Group Not sure which program to choose
Personal and Contact Information (ALT+P):
*Last name:
*First name:
*Home phone:
Work Phone:
Cell phone/pager:
Email address:
*Street address: (include floor and apt. #)
*City:
*State:
*Zip code:
*Your race/ethnicity of youth (Check ONE only):		Race: American Indian/Alaska Native Asian Black/African-American Hispanic/Latino Native Hawaiian/Pacific Islander White/Caucasian Other If other describe:

*Marital status (choose ALL that apply):		Marital Status Married, spouse present Married, spouse absent Unmarried, living with partner Widowed Divorced Never married Other If other describe
*Date of birth (mm/dd/yy):		Age:
*Gender:		Male Female
*Primary language spoken at home:
*Number of Adults Living in Household:
*Number of Youth 18 and Under Living in Household:
Parenting Profile (ALT+G):
*Please give a brief summary of your experience parenting a child with a disability.


*Why are you interested in participating in Parents Chat Online?


*List specific topics related to parenting and disability issues that you are interested in learning about.


*Do you have any specific areas of expertise or resources you are interested in sharing with other parents? If so, please list them below.


Education/Employment Experience (ALT+E):
*What is your employment status? (Check ONE only)		Employment Status Unemployed Employed Retired Student Other If other describe
Current Employer/School:
Length of Employment:

If not a student, which of the following best characterizes current or immediate past employment?		Past Employment Managerial/professional Technical/sales/administrative Service Military Law enforcement/justice Religious Other: If other describe

*What is your highest level of education completed? (Check ONE only)		Education High school diploma College courses Associate's degree BA/BS degree Master's degree Doctoral degree Other: If other describe
Nature of Your Child's Disability (ALT+D):
*What is the nature of your child's disability? (check ALL that apply):		Disability Type None Physical Blind/Low Vision Deaf/Hard of Hearing Deaf-Blind Learning Cognitive Emotional Other If other describe

If you checked more than one box above, what is your CHILD'S primary disability?

Primary Interest in Joining Parents Group (ALT+J):
*What is your primary reason for applying to participate in Parents Online Chat? (Check ONE only)		Reason To learn more about disability resources To help other parents To gain support from other parents To help plan for my child's future Other: If other describe:
Final Steps (ALT+Z):
Review the entire form and confirm that all of your answers are correct. Print and file a copy of this application with your personal records.

Parents Group Application

Start by Choosing the Programs You Are Interested in (ALT+S):

*Select a program (choose ALL that apply):

Personal and Contact Information (ALT+P):

*Last name:

*First name:

*Home phone:

Work Phone:

Cell phone/pager:

Email address:

*Street address: (include floor and apt. #)

*City:

*State:

*Zip code:

*Your race/ethnicity of youth (Check ONE only):

*Marital status (choose ALL that apply):

*Date of birth (mm/dd/yy):

*Gender:

*Primary language spoken at home:

*Number of Adults Living in Household:

*Number of Youth 18 and Under Living in Household:

Parenting Profile (ALT+G):

*Please give a brief summary of your experience parenting a child with a disability.

*Why are you interested in participating in Parents Chat Online?

*List specific topics related to parenting and disability issues that you are interested in learning about.

*Do you have any specific areas of expertise or resources you are interested in sharing with other parents? If so, please list them below.

Education/Employment Experience (ALT+E):

*What is your employment status? (Check ONE only)

Current Employer/School:

Length of Employment:

If not a student, which of the following best characterizes current or immediate past employment?

*What is your highest level of education completed? (Check ONE only)

Nature of Your Child's Disability (ALT+D):

*What is the nature of your child's disability? (check ALL that apply):

If you checked more than one box above, what is your CHILD'S primary disability?

Primary Interest in Joining Parents Group (ALT+J):

*What is your primary reason for applying to participate in Parents Online Chat? (Check ONE only)

Final Steps (ALT+Z):

*Street address:
(include floor and apt. #)