Coffee and Conversations Wednesdays

Join Coffee and Conversations on Wednesdays at 2pm if you have children with complex medical needs.

Question Title

* 1. Please provide your contact information.

Name

Email Address

Phone Number

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* 2. What county do you live in?

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* 3. What is your race?

Black or African American

White or Caucasian

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Multiple Races

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* 4. What is your ethnicity?

Hispanic or Latino

Non-Hispanic or Latino

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* 5. Please provide your child's date of birth.

Date of Birth

Date

Question Title

* 6. What is your child's race?

Black or African American

White or Caucasian

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Multiple Races

Question Title

* 7. What is your child's ethnicity?

Hispanic or Latino

Non-Hispanic or Latino

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* 8. What is your child's diagnosis? Please check all that apply.

Autism

ADD/ADHD

Deaf/Blind

Developmental Delay

Intellectual Disability

Deaf/Hearing Impairment

Emotional Disability

Learning Disability

Multiple Disabilities

Other Health Impairment

Orthopedic Impairment

Speech & Language

Traumatic Brain Injury

Vision Impairment/Blind

Suspected Disability

None

Other (please specify)

Coffee and Conversations *Wednesdays*

Question Title

* 1. Please provide your contact information.

Question Title

* 2. What county do you live in?

Question Title

* 3. What is your race?

Question Title

* 4. What is your ethnicity?

Question Title

* 5. Please provide your child's date of birth.

Question Title

* 6. What is your child's race?

Question Title

* 7. What is your child's ethnicity?

Question Title

* 8. What is your child's diagnosis? Please check all that apply.

Coffee and Conversations Wednesdays